APRIL 2014

Low-cost IVF expands global

access to infertility care

SINGAPORE
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Can stem cells treat to women
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Low-cost IVF expands global access
to infertility care
CHRISTINA LAU
T he recent development of low-cost in vitro
fertilization (IVF) programs may expand ac-
cess to infertility treatment not only in resource-
poor countries, but also in the developed world.
One innovative program, developed at the
University of Colorado Boulder (UC-Boulder),
US, reduces the cost of IVF to just around USD
250 per cycle.
The researchers made this possible by sim-
plifying the entire procedure of IVF, using gener-
ic fertility drugs and basic laboratory equipment
that can fit inside a shoebox, explained Profes-
sor Gab Kovacs of Monash IVF and Monash
University, Melbourne, Australia. Kovacs was
speaking during the 19th World Congress on
Controversies in Obstetrics, Gynecology & In-
fertility (COGI) held recently in Macau.
Using two test tubes and inexpensive chemi-
cals, the UC-Boulder researchers developed a
low-cost embryo culture method that can gen-
erate conditions very similar to what others are
generating with a USD 60,000 incubator.
In the first test tube, citric acid and sodium
bicarbonate are used to prepare a solution con-
taining carbon dioxide, which creates the ideal
conditions for fertilization, he explained. This
is then piped into the second test tube, where
A P R I L 2 01 4 2
oocytes and sperms are injected by syringe
without disturbing the air environment inside the
tube. Any resulting embryo is examined under a
microscope before transfer.
In a proof-of-principle study of IVF patients
aged <36 years with at least eight oocytes avail-
able for fertilization, the low-cost culture method
resulted in similar rates of fertilization and em-
bryo cleavage compared with conventional IVF
culture systems. [European Society of Human
Reproduction and Embryology 2013 Annual
Meeting, abstract 14]
Importantly, the ongoing pregnancy rate was
30.4 percent similar to rates achieved in con-
ventional IVF programs. According to the re-
searchers, this means infertility care may now
be universally accessible.
In June 2013, Australias largest infertility
treatment provider launched low-cost IVF clinics
in low-income suburbs of Sydney, Melbourne
and Brisbane, providing IVF treatment with
minimal stimulation and monitoring. This was
followed by another treatment provider, who
launched a low-intervention IVF service with
electronic interface with patients.
While the success rates may be lower with
these models, they offer affordable IVF services
to patients who would otherwise have struggled
to access the full service, said Kovacs.

TB prevalence in China markedly
reduced
CASSIE-ANNE LOW
C hinas tuberculosis (TB) control policies
are being credited for leading to a marked
reduction in the prevalence of the disease in the
country by over a half in the past 20 years.
A recently published study, involving a
20-year-long analysis of Chinas national survey
data, has indicated a drop in TB prevalence from
170 to 59 per 100,000 people. [Lancet 2014.
doi:10.1016/S0140-6736(13)62639-2]
The fall follows a scale-up of the directly ob-
served treatment short-course (DOTS) strategy
from half the population when it was first intro-
duced in the 1990s, to the entire country after
2000.
One of the key global TB targets set by the
Stop TB Partnership aims to reduce tuberculo-
sis prevalence by 50 percent between 1990 and
2015. This study in China is the first to show the
feasibility of achieving such a target, and Chi-
na achieved this 5 years earlier than the target
date, said Dr. Yu Wang, study leader, Chinese
Center for Disease Control and Prevention,
based in Beijing, China. Huge improvements in
TB treatment, driven by a major shift in treatment
from hospitals to local public health centers im-
plementing the DOTS strategy, were largely re-
sponsible for this success.
China is one of the largest contributors to the
global TB pandemic, with 1 million new cases
each year, accounting for 11 percent of all new
A P R I L 2 01 4 3
cases globally. In the 1990s, the country began
addressing this issue, launching the internation-
ally recommended DOTS strategy in 13 prov-
inces containing half the population.
Two national surveys on the prevalence of
TB were conducted in 1990, and in 2000, when
the program was rolled out across the country.
Over that decade, it was found that the number
of TB cases was reduced by about 30 percent
in the areas where the DOTS program was im-
plemented. Nationally however, the number of
cases dropped by just 19 percent.
Most recently, a survey of TB prevalence was
conducted in 2010 to explore the impact, if any,
of the introduction of the DOTS program nation-
wide. Around 253,000 individuals aged 15 years
and above took part in the survey and the results
showed a drop of 57 percent, with 70 percent of
the total reduction in smear-positive prevalence
(78 of 111 cases per 100,000 population) taking
place after 2000. Of these, 87 percent were cas-
es already diagnosed with TB prior to the survey,
with the number of cases treated using the DOTS
strategy increasing from 15 percent in 2000, to 66
percent in 2010. These cases also contributed to
a reduction in the percentage of treatment default
(from 43 percent to 22 percent; p<0.0001) and
retreatment cases (from 84 percent to 31 per-
cent; p<0.0001).
The DOTS program has been much more
effective in reducing the prevalence of tubercu-
losis in known cases than in new cases, wrote
 A P R I L 2 01 4 4

the study authors. to be considered by the 2014 World Health As-

In an accompanying editorial, Dr. Giovanni
Battista Migliori, director, WHO Collaborating
Center for Tuberculosis and Lung Diseases in
Italy, and Dr. Giovanni Sotgiu, University of Sas-
sari-Research in Italy, said these data are im-
portant for the global TB control and elimination
agenda. [T]he new tuberculosis targets likely
sembly include a 50 percent reduction in tuber-
culosis between 2015 and 2025.
The results from China show the feasibility of
achieving such a target by aggressively scaling
up the basic programmatic elements of tubercu-
losis control both within and outside the public
sector.

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 A P R I L 2 01 4 FORUM 5

Reality begins to dawn over potential

of e-cigarettes
The debate continues over the place of electronic cigarettes (e-cigarettes), a disruptive
innovation which some say has the potential to make combustible cigarettes obsolete.

T he uptake of e-cigarette use by nicotine
consumers in the US and Europe over the
past 5-7 years has been nothing short of re-
markable. Millions of people in these markets
have now switched from smoking to vaping.
However, not everyone is happy, convinced
or willing to accept this new development
and well-funded public relations campaigns
have sprung up attempting to persuade pol-
icy-makers, the media and the public that
e-cigarettes should be regulated or banned
because they are harmful or a gateway to
tobacco smoking. While these campaigns
have had some success, they now appear to
be unraveling.
Major media outlets in the US and Europe
have begun to cast their nets wider in terms of
who they interview for e-cigarette stories and
have provided better, more balanced coverage
of this hotly contested topic. Could it really be
that health reporters (and even the general pub-
lic) are becoming increasingly skeptical about
the possible hazards of e-cigarettes? It does
seem that some have begun to question the sci-
entific credibility of negative e-cigarette-related
studies.

Debunking dubious science
Case in point: In early March, a study by Drs.
Stanton Glantz and Lauren M. Dutra from the
University of California, San Francisco (UCSF)
Center for Tobacco Control Research and Edu-
cation entitled Electronic cigarettes and con-
ventional cigarette use among US adolescents
was published online. [JAMA Pediatr 2014; Mar
6. doi:10.1001/jamapediatrics.2013.5488]
The study, a cross-sectional survey of adoles-
cents interviewed in a US National Youth Tobacco
Survey in 2011 and 2012, found e-cigarette use
to be associated with smoking status, heavier
smoking, and with fewer periods of smoking ab-
stinence. The authors concluded that e-cigarette
use among youths was therefore aggravating
rather than ameliorating the tobacco epidemic.
Their conclusion drew widespread criticism.
Professor Michael Siegel from the depart-
ment of community health sciences at Boston
University School of Public Health, Boston,
Massachusetts, US, responded immediately,
describing the authors conclusion as junk
science.[http://tobaccoanalysis.blogspot.
sg/2014/03/conclusion-of-new-glantz-study-on.
html?spref=tw]
The authors of this study make one of the
most cardinal errors in all of epidemiology. They
ignore the principle that correlation does not
equal causation, said Siegel.
They even admitted their study was a cross-sec-
tional study, which only allows for the identification
of associations, not causal relationships. However,
this did not stop them from coming to their conclu-
sion that e-cigarette use is aggravating the tobacco
epidemic among young people, he added.
A P R I L 2 01 4 FORUM 6
In my view, there is only one possible expla-
nation for this: Dr. Glantz is no longer playing
by the rules of science. He is now a man on a
mission: to destroy the e-cigarette industry and
to remove e-cigarettes as an option for smokers
trying to quit. He has apparently drawn the pre-
determined conclusion that e-cigarettes are ag-
gravating the tobacco epidemic among youth,
and he will stop at nothing to draw this conclu-
sion and disseminate it to the public.
The mainstream media, cancer interest
groups and anti-smoking organizations were
quick to pick up on the lack of scientific validity
of his latest studys conclusion.
In the New York Times, Thomas J. Glynn, a
researcher at the American Cancer Society, sim-
ply said: The data in this study do not allow
many of the broad conclusions that it draws.
Meanwhile, David Abrams, executive director of
the anti-smoking research group Schroeder In-
stitute for Tobacco Research and Policy Studies
at the Legacy Foundation, agreed, saying that:
I am quite certain that a survey would find that
people who have used nicotine gum are much
more likely to be smokers and to have trouble
quitting, but that does not mean that gum is a
gateway to smoking or makes it harder to quit.
[http://www.nytimes.com/2014/03/07/health/
young-users-of-e-cigarettes-less-likely-to-quit-
smoking-study-finds.html]
Fear of new technology
So why do some e-cigarette commentators
appear to be on a crusade to strike fear into the
heart of society?
In a recent article for Consumer Affairs, writer

Jennifer Abel took a swipe at US policy makers
and legislators who have lobbied or voted for
bans or regulation of e-cigarettes, suggesting
that such behavior is spurned on by magical be-
liefs.[http://www.consumeraffairs.com/news/
magical-beliefs-spawn-e-cig-bans-030514.html]
She described a historical precedent for re-
sistance to new technology. Primitive peoples
who relied on magic rather than science to ex-
plain how the world works often believed in what
is known as sympathetic magic the idea that
if item A looks like item B, that means A either
shares Bs traits or gives you actual power over
B, wrote Abel.
And belief in sympathetic magic appears to
be enjoying a renaissance among those who
oppose e-cigarettes or e-cigs, basically on the
grounds that a battery-operated metal tube emit-
ting water vapor looks like a burning tobacco cig-
arette emitting cancerous smoke... she added.
A P R I L 2 01 4 FORUM 7
What does common sense tell us?
While many opponents of e-cigarettes may
be prone to fear, others have been guided by
simple bias or a lack of information.
Vested interests (a list of which would be be-
yond the scope of this article) are a likely driver
for many. Many industries and institutions rely
on nicotine consumers to continue using the
more harmful, combustible tobacco products.
Others appear to possess an ideological dislike
of smokers so strong that they would prefer the
status quo to remain, ie, for cigarettes to retain
their harmful nature.
However, there is no escaping new technol-
ogy. What is needed therefore are rational poli-
cies informed by a scientific evidence-based ap-
proach, rather than agenda-driven ideological
beliefs.
Greg Town, Managing Editor
 A P R I L 2 01 4 N E WS 8

Asia at the forefront of biosimilar

market growth
CHRISTINA LAU

A sia is at the forefront of a burgeoning market

for biosimilars worldwide, with growth fueled
by an increasing burden of autoimmune diseas-
es and cancer, the presence of hundreds of do-
mestic biosimilar manufacturers, and substantial
cost savings with the use of their products.
In China alone, the biosimilar market is
worth USD 670 million. The country is projected
to contribute to 70 percent of global growth in
pharmaceutical spending in 2010-2015, pre-
dominantly driven by generics, said Dr. Alex
Kudrin of Celltrion Inc., Korea, at the Hong Kong
Pharmacy Conference.

U
 ltimately, biosimilars are there
to benefit patients and healthcare
providers by reducing costs and
delivering biologic therapy
to more patients 
With biosimilars accounting for 40 percent of
Chinas recombinant biologic product sales, the
country has seen a compound annual growth
rate of 25-30 percent in the industry over the last
10 years.
This growth was led by a group of domes-
tic products, said Kudrin. In fact, the first
biosimilars made in China were approved and
launched even before the reference biologics
entered the Chinese market. Biosimilar etan-
In China alone, the biosimilar market is worth USD 670
million
ercept, for example, was launched in China in
2006, 5 years before the reference product be-
came available.
Costing on average 60 percent less than the
reference biologics, these domestic biosimilars
are attractive treatment options for a growing
number of Chinese patients with rheumatoid
arthritis, psoriasis, inflammatory bowel disease
and cancer.
Targeted therapies for cancer, for example,
are unaffordable to many patients in China as
some of the reference products cost more than
the average annual income of urban employ-

ees, pointed out Kudrin. China has a high un-
met need for affordable biosimilar monoclonal
antibodies for cancer, and a few are already in
clinical development.
India faces a similar situation of increasing
disease burden and low affordability of biolog-
ics. With about 100 domestic biosimilar manu-
facturers contributing to USD 363 million in
sales or 30.25 percent of the global biosimilar
market, continued growth is expected.
Indias biosimilar industry is the third larg-
est in Asia, after China and South Korea, said
Kudrin. More than 20 biological molecules and
50 brands have been approved for marketing in
India, and domestic companies have the capa-
bility to manufacture approximately 75 percent
A P R I L 2 01 4 N E WS 9
of them.
The regulatory picture in emerging Asian
markets is, however, heterogeneous. While In-
dia has issued its own biosimilar guidelines that
are well harmonized with WHO, EMA and FDA
principles, relevant guidelines are still in devel-
opment in China. Inception of the China FDAs
biosimilar guidelines is expected in the third
quarter of 2014 or in 2015, said Kudrin.
As biosimilars are a relatively new market,
regulatory guidelines and standards will evolve
constantly as technology develops. Ultimate-
ly, biosimilars are there to benefit patients and
healthcare providers by reducing costs and
delivering biologic therapy to more patients,
Kudrin concluded.

Changes in postpartum sexuality
occur in both parents
LAURA DOBBERSTEIN
P arents experience a change in sexuality fol-
lowing the birth of a child, with low sexual
desire linked to factors related to the care of the
baby like stress and fatigue, suggests new re-
search in the US.
The retrospective online survey, involving
114 partners of postpartum women (95 men, 18
women, 1 unspecified), questioned new parents
about their sexuality in the 3 months following the
birth of their youngest child to determine changes
in physical, social, psychological and relational
experiences.
The results showed that in the first 3 months
following birth, 81.7 percent of partners reported
reengagement of sexual intercourse with the birth
mother, 69.6 percent reported participating in
oral sex and 72.7 percent reported masturbating.
Masturbation occurred earlier in the postpartum
period than did intercourse (p<0.001), oral sex
on the mothers partner (p<0.048) or oral sex on
the birth mother (p<0.001). There were no sig-
nificant differences in the time it took to reengage
in intercourse and oral sex on either parent. The
mothers partner enjoyed reported higher enjoy-
ment with oral sex than intercourse or masturba-
tion (all p<0.030), but there was no significant
differences in enjoyment between intercourse
and masturbation (p=0.902). Both groups par-
ticipated equally in initiation of postpartum inter-
course (p=0.359).
A P R I L 2 01 4 N E WS 10
A study has shown that parents typically experience a
change in their sexuality after the birth of a child.
Participants ranked factors related to sexual
and intimate feeling in participants and their part-
ners as most frequently contributing to high de-
sire and fatigue and stress as the top influences
for low desire. Time constraints was selected as
the third most common factor contributing to low
postpartum sexuality. There were no significant
differences between the genders in self-reported
perceived stress, body image self-consciousness
or average level of fatigue (all p>0.40). However,
women partners of new mothers perceived more
support from their significant others and friends
and had significantly higher overall social sup-
port scores than their male counterparts (all
p<0.035).
Results from this study and previous re-
search suggest that postpartum sexuality can be
conceptualized as an individualized experience

within a partnership, as well as one that occurs in
a larger social and relational context, said study
author Dr. Sari M. van Anders of the University
of Michigan, Ann Arbor, Michigan, US, and col-
leagues.
While most studies on postpartum sexu-
ality focus on the birth mother, few if any have
examined the role of sexuality in the mothers
partner and whether this in turn influences the
birth mothers perception of her own sexuality,
said Dr. Juan Dominguez, principal investigator
of the Neuroendocrinology and Motivation Lab at
the University of Texas at Austins Department of
Psychology.
A P R I L 2 01 4 N E WS 11
Dominguez warned that these gender-specific
findings should be interpreted with caution due
to the small sample size of women partners and
time lapse between the postpartum period and
the collection of data.
This small caveat notwithstanding, the study
provides a clearer window in which to view the
postpartum sexuality of co-parents, how postpar-
tum sexuality may vary between partners gen-
der, and the idiosyncratic changes in sexual ac-
tivity that follow parturition, added Dominguez.
These findings will be a source of information for
health professionals who counsel mothers after
birth.

ATS updates guidelines for
managing pulmonary hypertension
in SCD patients
RADHA CHITALE
N ew guidelines from the American Thoracic
Society (ATS) outline management strate-
gies for treating pulmonary hypertension (PH) in
adults with sickle cell disease (SCD).
PH is a strong independent risk factor for
mortality in SCD, especially among patients who
are past their teens and early adulthood.
With the development of new treatments,
many patients with sickle cell disease are now
surviving long enough to develop pulmonary
hypertension, with an estimated prevalence of
6 to 11 percent, said Associate Professor Eliza-
beth S. Klings of the Boston University School
of Medicine and ATS guideline committee chair.
[Am J Respir Crit Care Med 189:6;727-740]
The panel of researchers advised that right
heart catheterization (RHC) was the most reli-
able way to diagnose PH. Doppler echocardiog-
raphy is a less invasive test but it has only 25
percent positive predictive value for moderate
tricuspid regurgitant jet velocity (TRV), although
it can be used to confirm diagnosis in conjunc-
tion with other tests.
A review of related literature showed that
elevated TRV and increased serum N-terminal
pro-brain natriuretic peptide (NT-pro-BNP) levels
are also independent risk factors for mortality in
SCD patients.
A P R I L 2 01 4 N E WS 12
New guidelines look to optimize management strategies
for pulmonary hypertension in patients with sickle cell
disease.
In spite of these known risk factors for SCD
mortality, Klings said there is no standardized
approach for patient treatment and follow-up.
Among the recommendations, the guidelines
recommend hydroxyurea as first-line therapy
for SCD patients with increased mortality risk.
Chronic transfusions were a less preferable al-
ternative for patients who were not candidates
for hydroxyurea.
Most patients with confirmed PH were also
not likely candidates for targeted pulmonary ar-
terial hypertension therapy, unlike SCD patients
with other mortality risk factors, and clinicians
should opt instead for a trial of a prostanoid or
an endothelin receptor antagonist.
We need to continue our research efforts
into this disease and its management to under-
stand what the optimal treatment regimen for
these patients is, Klings said. Most of our cur-
rent recommendations are limited by a lack of
large-scale clinical trials in this population.

Shortness of breath when bending
forward identified as novel symptom
of heart failure
ELVIRA MANZANO
C ardiologists have identified a new symp-
tom of heart failure bendopnea or short-
ness of breath when bending forward.
Heart failure frequently presents with dys-
pnea on exertion, orthopnea and paroxysmal
nocturnal dyspnea, but many patients complain
of shortness of breath when bending forward,
such as when putting on their shoes or socks,
said Professor Jennifer Thibodeau from the Uni-
versity of Texas Southwestern Medical Center in
Dallas, Texas, US. Some patients thought they
were short of breath because they were out of
shape or overweight.
To determine the frequency and hemody-
namic correlates of bendopnea with heart fail-
ure, Thibodeau and colleagues assessed 102
adult patients with systolic heart failure referred
to a cath lab unit for right heart catheterization
between June 2010 and May 2012. Approxi-
mately one-third (n=29) of the study cohort
had bendopnea, with median time to onset of
8 seconds. Patients with bendopnea had higher
supine right atrial pressure (RAP, p=0.001) and
pulmonary capillary wedge pressure (PCWP,
p=0.0004) and lower pulmonary artery oxygen
saturation and cardiac index (CI) compared with
those without bendopnea. RAP and PCWP fur-
ther increased with bending, but cardiac index
A P R I L 2 01 4 N E WS 14
Some patients thought they were out of breath due to
being overweight or unfit.
remained low. [J Am Cardiol 2014;2:24-31]
Our findings confirmed what we have been
seeing in our patients, said Thibodeau. These
patients had too much fluid in their bodies, caus-
ing elevated right and left ventricular filling pres-
sures. When they bent forward, these pressures
increased even more.
Accurate assessment of hemodynamic sta-
tus is critical to the proper treatment of heart
failure. Bendopnea may be useful for physicians
who are not adept at estimating jugular venous
pressure, said Thibodeau. She however cau-
tioned that bendopnea is not a risk factor for
heart failure, rather a symptom that patients are
becoming sicker and may need to adjust their
medications or treatment.
As the current study consisted only of pa-
tients referred for right-heart catheterization, ad-
ditional studies are warranted to determine the
prevalence of bendopnea in the general heart
failure population, the investigators said.
 A P R I L 2 01 4 N E WS 15

Antidepressants may quell agitation

in Alzheimers disease
RADHA CHITALE

T he antidepressant citalopram quelled

agitation in patients with Alzheimers dis-
ease in a placebo-controlled parallel-group
trial.
Agitation, defined as emotional distress, ex-
cessive psychomotor activity, agitative behav-
iors, disruptive irritability and disinhibition, is a
common and severe comorbidity of Alzheim-
ers disease affecting up to 90 percent of
patients with repercussions for both patients
and caregivers.
These symptoms are a major reason why
people go into long-term care prematurely,
said lead researcher Dr. Bruce G. Pollock, vice
president of Research at the Centre for Addic-
tion and Mental Health (CAMH) in Toronto, On-
tario, Canada.
However, therapy, exercise and pharmaco-
logic treatments antipsychotic drugs in par- Citalopram may be a promising alternative to
antipsychotics.
ticular have proved unsuccessful in many
cases. The current study randomized patients
Antipsychotics are not an ideal therapy and with probable Alzheimers disease and clini-
significantly increase the risk of strokes, heart cally significant agitation to citalopram (n=94,
attacks and sudden death, Pollock said. 10 mg/day titrated up to 30 mg/day based on
Smaller trials have demonstrated probable response or need) or placebo (n=92) for 9
efficacy of citalopram, a selective serotonin weeks. [JAMA 2014;311:682-691]
reuptake inhibitor (SSRI) for agitation among Both groups received psychosocial inter-
elderly people with dementia, but it has not vention in the form of educational materials,
been examined for use against Alzheimers- crisis management, and counseling sessions
related agitation. after scheduled study visits to review their sup-

portive care plan.
Citalopram treatment led to a [clinically
relevant] reduction in agitation in patients with
Alzheimers disease, the researchers said.
The estimated treatment difference for agita-
tion, measured by the Neurobehavioral Rating
Scale agitation subscale, was -0.93 between
the citalopram and placebo arms (p=0.04).
Forty percent of patients receiving citalo-
pram had moderate or marked improvement
from baseline on the modified Alzheimers
Disease Cooperative Study-Clinical Global Im-
pression of Change score compared with 26
percent of placebo patients (p=0.01).
Caregivers also benefited from citalopram-
treated patients, showing reduced distress
(p=0.02) compared with the placebo arm.
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A P R I L 2 01 4 N E WS 16
Adverse events due to citalopram were
consistent with those known for SSRI therapy,
including gastrointestinal issues, respiratory
tract infections and falls.
Citalopram patients did experience worsen-
ing cognition and some negative cardiac ef-
fects, particularly in the 30 mg dose, and the
researchers cited short treatment duration
and unknown effects of citalopram on different
types of dementia and agitation as trial limita-
tions.
An assessment of individual patient circum-
stances, including symptom severity and
effectiveness of behavioral interventions can
help guide appropriate medication use in pa-
tients with marked agitation or aggression, the
researchers said.
 A P R I L 2 01 4 N E WS 17

Sweet tooth linked to raised CVD risk

ELVIRA MANZANO

C onsuming more than 10 percent of total

daily calories from sugar (added in pro-
cessing or preparing food) increases the risk of
dying from cardiovascular disease (CVD).
The finding was from a study of 31,147 adults
in the US, based on data from the National Health
and Nutrition Examination Survey from 1988 to
2010. [JAMA Intern Med 2014; doi:10.1001/ja
mainternmed 2013.13563]
Over a median follow-up period of 14.6 years,
people who consumed 10 to 24.9 percent of cal-
Consuming more than 10 percent of total daily calories
ories from sugar had a 30 percent higher risk of from sugar may increase risk of CV-related mortality.

CVD-related mortality compared with those who

consumed less than 10 percent (hazard ratio
[HR] 1.30, 95% CI 1.09-1.55).
The risk of death further increased in those
who had 25 percent or more of their calo-
ries from sugar (HR 2.75, 95% CI 1.40-5.42).
Overconsumption of added sugar was as-
sociated with increased CVD mortality even
after adjusting for other risk factors such as
high blood pressure and elevated total serum
cholesterol.
The findings were consistent across age
group, sex and race/ethnicity except in non-
Hispanic blacks, said Dr. Quanhe Yang from the
Centers for Disease Control and Prevention, Di-
vision of Heart Disease and Stroke Prevention,
in Atlanta, US, and colleagues.
In an accompanying editorial, Dr. Laura
Schmidt of the University of California, San Fran-
cisco, US, said the findings provide physicians
and consumers with actionable guidance.
Added sugar is a significant risk factor for cardio-
vascular disease mortality above and beyond its
role as empty calories leading to weight gain and
obesity, she added. The findings also have ad-
ditional implications for public policies affecting
racial/ethnical disparities in nutrition and food en-
vironments. [JAMA Intern Med 2014;doi:10.1001/
jamainternmed. 2013.12991)
The World Health Organization (WHO) rec-
ommends a 10 percent threshold for total dai-
ly caloric intake from added sugar. In its latest
guidelines, the agency introduces a secondary
caveat which advises further reduction to less
than 5 percent for additional benefits.
 A P R I L 2 01 4 N E WS 18

World Diabetes Day in November:

Is your city diabetes aware?
CASSIE-ANNE LOW

T his year, World Diabetes Day will take place

on November 14, and the International Dia-
betes Federation (IDF) and European Connect-
ed Health Alliance (ECHAlliance) are challeng-
ing cities around the world to become diabetes
aware.
Together with an expert group consisting of
NGO, business and mobile health sector rep-
resentatives, the IDF and ECHAlliance will tap
on the accessibility and convenience of mobile
technology to develop the scheme.
The aim of the diabetes aware scheme is to
create an international network of cities that not
only promote awareness about the condition,
but also provide support for people living with
diabetes through the use of mobile health tools
and apps.

B
 y 2035, one in 10 of the worlds
population will have diabetes
unless there is radical change.
People in urban areas will be
particularly vulnerable. Socially
Diabetes affects 382 million people globally.
and economically, this diabetes
epidemic will be very costly.  a healthy and supportive environment not only
for people living with diabetes, but also those at
In order for a city to be labeled diabetes risk of developing the disease.
aware, it would need to show that its public ser- Speaking about the prevalence of diabe-
vices and businesses are committed to creating tes and its effects, Dr. Petra Wilson, CEO, IDF,

said: By 2035, one in 10 of the worlds popu-
lation will have diabetes unless there is radical
change. People in urban areas will be partic-
ularly vulnerable. Socially and economically,
this diabetes epidemic will be very costly. It
is important that we find new ways of work-
ing across all sectors to provide people with
targeted information on healthier lifestyle op-
tions.
Some ways in which a city can become dia-
betes aware are by providing its residents with
important lifestyle tools such as the nutritional
information of restaurants or by ensuring that all
green spaces such as parks are safe and acces-
sible for exercise.
A P R I L 2 01 4 N E WS 19
Providing people with mobile information on
healthier places to eat, shop and exercise in cit-
ies is the first step toward making the healthy
choice the easy choice. Information is the key
to enabling healthy choices, said Mr. Brian
OConnor, chair of the ECHAlliance, when asked
about the new partnership.
Diabetes is a disease that affects some 382
million people worldwide, or 8.3 percent of the
global population [International Diabetes Feder-
ation, IDF Diabetes Atlas, 6th edn. Brussels, Bel-
gium: International Diabetes Federation, 2013.
http://www.idf.org/diabetesatlas]. It is predicted
that this number will rise to 592 million by the
year 2035.

High-calorie diet well tolerated in
patients with ALS
CASSIE-ANNE LOW
P atients with amyotrophic lateral sclerosis
(ALS), also known as motor neuron dis-
ease, or Lou Gehrigs disease, tolerated a high-
carbohydrate, high-calorie diet well, according
to a phase II study.
Previous findings suggest that mildly over-
weight ALS patients may live longer if fed a diet
rich in calories and fat.
In a 4-month randomized double-blind study
involving 20 patients with ALS, those receiving
a high-carbohydrate/high-calorie diet experi-
enced a lower total number of adverse effects
than a control group and a high-fat/high-calorie
group (23 vs 42 and 48, respectively). They also
experienced significantly fewer serious adverse
effects compared with the control group (0 vs
9, respectively; p<0.0005), including death from
respiratory failure. [Lancet 2014; doi:10.1016/
S0140-6736(14)60222-1]
The high-carbohydrate/high-calorie diet group
was found to have gained slightly more weight
(average of 0.39 kg per month) when compared
with controls (0.11 kg per month) and the high-
fat/high-calorie group (-0.46 kg per month).
Speaking about the results, lead study
author Dr. Anne-Marie Wills, Massachusetts
General Hospital, Boston, US, said: There is
good epidemiological evidence that, in ALS,
survival is determined by nutritional status.
This pilot study demonstrates the safety of a
novel, simple, low-cost treatment for a dev-
astating disease where currently, very few
treatment options are available. The adverse
outcomes that we feared might result from
weight gain, such as diabetes or heart dis-
ease, were not observed in our study period
A P R I L 2 01 4 N E WS 20
Outcomes that might have been expected from a high
carb/high calorie diet, such as weight gain, were not
seen.
of 5 months.
Despite the positive results, Wills and her
team pointed out the limitation of the studys
small sample size and have called for larger tri-
als with similar nutritional interventions on pa-
tients at an earlier stage in the disease.
In a linked comment, Dr. Ammar Al-Chala-
bi, Kings College London, UK, stated that he
would not be changing his advice to patients
on the basis of the study. However he is look-
ing forward to the results of a large phase III
trial. Wills and colleagues have taken the first
steps needed to provide evidence for a robust,
non-pharmacological treatment that is well tol-
erated and easy to administer. We must finish
the work they have started, he added.
ALS is a rapidly progressive, neurodegen-
erative disorder that affects the nerve cells
that control muscle movement. ALS sufferers
gradually lose the ability to control voluntary
muscles, including the muscles that control
breathing. This eventually leads to respiratory
failure and death around 3 years after the initial
diagnosis.
 A P R I L 2 01 4 R E S E A R C H R E V I E WS 21

Clopidogrel for a year after PCI reduces re-hospitalization for ACS

T he optimal duration of dual antiplatelet

therapy after percutaneous coronary inter-
vention (PCI) appears to be between 12 and 15
months, according to a recent study performed
in Taiwan.
The retrospective, cohort study examined the
effects of 9 months, 12 months, and 15
months of dual antiplatelet therapy (clopidogrel
plus aspirin) on the risk of re-hospitalization for
acute coronary syndrome (ACS) among 975
newly diagnosed ACS patients who underwent
PCI between July 2007 and June 2009.
After a mean follow-up of approximately 2
years, clopidogrel therapy for 9 months was
found to have only a minimal effect on reducing
re-hospitalization rates for ACS (adjusted haz-
ard ratio [HR] 0.69, 95% CI 0.481.00, p=0.05),
while 12 months of therapy was associated
with a statistically significant 40 percent de-
crease in the risk of re-hospitalization for ACS
(adjusted HR 0.59, 95% CI 0.360.95, p=0.03).
However, no such benefit was observed after justed HR 0.76, 95% CI 0.371.56, p=0.45).
15 months clopidogrel therapy (adjusted HR The researchers concluded that their findings
0.57, 95% CI 0.291.13, p=0.11). Similar re- support the latest American College of Cardiolo-
sults were observed for patients implanted with gy/American Heart Association guidelines.
drug-eluting stents (9 months of therapy: ad-
justed HR 0.68, 95% CI 0.441.06, p=0.09; 12 Chen SC et al. Duration of dual antiplatelet therapy following

months of therapy: adjusted HR 0.52, 95% CI percutaneous coronary intervention on re-hospitalization for acute

0.290.92, p=0.02; 15 months of therapy: ad- coronary syndrome. BMC Cardiovascular Disorders 2014;14:21

Harm reduction programs benefit sex workers in China
T he estimated 140-fold increase in the num-
ber of commercial sex workers in China be-
tween 1985 and 2000 has occurred at the same
time as a 147-fold increase in the number of an-
nually reported cases of notified sexually trans-
mitted diseases, including HIV/AIDS and syphi-
lis. The Chinese government has implemented a
number of harm reduction programs to address
the issue, and a recent study assessed the im-
pact of these programs on HIV and syphilis and
related risk behaviors among female sex work-
ers in the drug trafficking city of Xichang in Sich-
uan province.
The study reports findings from two cross-
sectional surveys conducted among female sex
workers before (2004, n=343) and after (2010,
n=404) the launch of the programs.
The odds of syphilis infection decreased by
35 percent between 2004 and 2010 (adjusted
odds ratio [OR] 0.65; 95% CI 0.411.03, p=0.07),
while the odds of unprotected sex with clients
A P R I L 2 01 4 R E S E A R C H R E V I E WS 23
declined remarkably and significantly (adjusted
OR 0.14, 95% CI 0.090.21, p<0.0001), and the
odds of HIV testing were greatly increased (ad-
justed OR 2.59; 95% CI 1.793.73, p<0.0001).
However, the odds of HIV infection appeared
to increase over the same period (adjusted OR
4.12; 95% CI 0.7622.45, p=0.10) and the odds
of reporting 10 new sex partners in the previ-
ous month increased by 37 percent (adjusted
OR 1.37; 95% CI 0.981.09, p=0.07).
The researchers concluded that the harm re-
duction programs have been of some benefit as
they have reduced the incidence of unprotected
sex with clients, increased the prevalence of HIV
testing, and reduced the risk of syphilis infec-
tion.
Zhang L et al. HIV, syphilis, and behavioral risk factors among
female sex workers before and after implementation of harm
reduction programs in a high drug-using area of China. PLOS One
2014;9(1):e84950
 A P R I L 2 01 4 DR U G P R O F I L E 24

Glycopyrronium bromide: Novel

once-daily inhaled COPD treatment
Chronic obstructive pulmonary disease (COPD) is a progressive illness characterized
by chronically poor airflow resulting in shortness of breath, cough, and elevated
sputum production. Potent treatments are needed to relieve the symptoms, delay
progression and prevent exacerbations. The current report reviews glycopyrronium
bromide (Seebri, Novartis), a new once-daily long-acting bronchodilator for treating
adult patients with COPD.

ALEXANDRA KIRSTEN, MD and abnormal sputum production. In later stag-

es, impaired quality of life and reduced exercise
Introduction capacity are frequently seen. [GOLD Report,
Chronic obstructive pulmonary disease updated version 2013]
(COPD) is characterized by progressive airflow COPD is the fourth leading cause of death
limitation that leads to breathlessness, cough worldwide. Affecting almost 6 percent of the

global population, it is estimated to have caused
the death of 3 million people in 2011. [WHO,
Fact Sheet N 310, July 2013]
Smoking tobacco is the most common and
best-studied risk factor for the development of
COPD. Other contributing factors, such as air
pollution from biomass fuels and poorly vent-
ed cooking fires, are thought to play a smaller
role [GOLD Report, updated version 2013]. It
is important to remember however that non-
smokers are also affected by the disease as
shown in different epidemiologic studies [Chest
2011;139:752-763, Am J Med 2005;118:1364-
1372].
COPD results from several pathological pro-
cesses interacting on a complex background of
genetic determinants, lung growth, and environ-
mental stimuli. [Lancet 2012;379:1341-1351]
Inflammation is the respiratory tracts normal
reaction to the inhalation of irritants. However,
the physiological response seems to be differ-
ent in individuals who develop COPD. In those
patients, a chronic amplified inflammatory reac-
tion with increased numbers of specific immune
cells can be found in the airways, lung paren-
chyma and pulmonary vasculature [Lancet
2004;364:709-721]. The persistent inflammation
causes fibrosis and narrowing of the small air-
ways (obstructive bronchiolitis) and destruction
of the lung parenchyma (emphysema). These
alterations lead to air trapping and progressive
poor airflow causing dyspnea and other symp-
toms of COPD. In general, the inflammatory and
structural changes in the airways increase with
disease severity and persist also on smoking
cessation.
A P R I L 2 01 4 DR U G P R O F I L E 25
COPD has no cure yet, but its symptoms are
pharmacological manageable and its progres-
sion can be delayed. [GOLD Report, updated
version 2013]
The major treatment goals are to relieve
symptoms, manage stable COPD with associ-
ated illnesses, improve the exercise tolerance
and prevent and treat acute exacerbations.
[Am J Respir Crit Care Med 2007;176:532-555].
Treatment options may include supplemental
oxygen, corticosteroids and long-term antibiot-
ics. However, inhaled bronchodilators, includ-
ing long-acting muscarinic antagonists (LAMAs)
are the cornerstone of the pharmacological
therapy. LAMAs seem to have a positive impact
on prevention and control of symptoms, sever-
ity and rate of exacerbations, quality of life, and
exercise capacity [Ther Clin Risk Manag 2013;9:
341-353]. Therefore they are recognized as first-
line maintenance therapy in COPD. Before the
approval of glycopyrronium bromide, tiotropium
was the only LAMA approved for the manage-
ment of COPD. [GOLD Report, updated version
2013, N Engl J Med 2010;362:1407-1416]
Glycopyrronium bromide
Pharmacology and pharmacodynamics
Glycopyrronium bromide is a synthetic qua-
ternary ammonium compound belonging to the
LAMA drug class.
The drug acts as a competitive antagonist
by binding to muscarinic receptors in bronchial
smooth muscle and thereby inhibiting acetyl-
choline-induced bronchoconstriction. The mol-
ecule binds with different affinities to all five sub-
types of the muscarinic receptor (M1M5). [Int J

COPD 2012;7:673-678]
However, the bronchodilatory effects result
from blockade of M1 and especially M3 recep-
tors. M3 receptors are located on airway smooth
muscles and primarily involved in the promo-
tion of their contraction, whereas M1 receptors
are involved in transmission of nerve impulses.
[Mol Pharmacol 2009;76:543-551, Respiration
2002;69:372-379]
Blockade of M2 receptors reduces broncho-
dilating effects of an antimuscarinic agent and
increases the heart rate. Thus, an antimusca-
rinic agent for use in COPD, like glycopyrronium
bromide, should have a high affinity for M1 and
M3 and a low affinity for M2 receptors. [Ther
Adv Respir Dis 2011;5:163-173, Int J COPD
2012;7:673-678]
Glycopyrronium bromide is used in anesthe-
sia as a preoperative antimuscarinic to reduce
gastric secretion, to block cardiac vagal reflexes
during surgery, and to protect against the pe-
ripheral muscarinic actions of anticholinester-
ases. The drugs once-daily dry-powder formu-
lation for the treatment of COPD is also known
as NVA237. [AusPAR Seebri Breezhaler/Tovanor
Breezhaler Novartis Pharmaceuticals Australia
Pty Ltd PM-2011-02800-3-5 Final July 2013]
Clinical efficacy
Early small trials provided clinical evidence
for the use of glycopyrronium in the treatment
of COPD. In these studies, the drug was found
to be well tolerated and demonstrated rapid and
sustained 24-hour bronchodilatation. [Respir
Med 2010;104:1482-1489, Pulm Pharmacol Ther
2010;23:438-444, Respir Med 2011;105:337-
A P R I L 2 01 4 DR U G P R O F I L E 26
342]
Glycopyrronium was approved for use in
the treatment of COPD based on data from the
phase III GLOW trials (glycopyrronium bromide
in COPD airways). The large-scale GLOW 1 and
2 studies involved a total of 1,888 patients with
stable, moderate-to-severe COPD requiring
maintenance treatment. The primary endpoint in
both studies was trough FEV1 after 12 weeks of
treatment. Trough FEV1 (forced expiratory vol-
ume in 1 second) is defined as the measure tak-
en in the morning prior to first dosing of inhaled
medications. [Int J COPD 2012;7:673-678]
In GLOW 1,822 patients were randomized to
receive either glycopyrronium bromide 50 g
once daily or placebo for 26 weeks.
At week 12, the mean trough FEV1 was
significantly higher in the glycopyrronium bro-
mide group than in the placebo group (1.41L vs
1.30L, respectively; p<0.001). These improve-
ments could be seen at the end of day 1 and
were sustained through week 26. FEV1 was sig-
nificantly better at all other scheduled visits and
time points during the study in patients receiv-
ing glycopyrronium bromide. In addition, the
drug significantly reduced the risk of first moder-
ate or severe COPD exacerbation by 31 percent
(p=0.023) and use of rescue medication by 0.46
puffs per day (p=0.005) versus placebo. [Respi-
ratory Research 2011;12:156]
A total of 1,066 patients in the GLOW 2 tri-
al were randomized to 1 years treatment with
either glycopyrronium bromide 50 g once
daily, open-label tiotropium 18 g once daily,
or placebo. The mean trough FEV1 at week 12
was found to be significantly higher in patients

receiving glycopyrronium bromide or tiotro-
pium compared with those receiving placebo
(p<0.001). These differences were maintained
at 12 months, though lung function declined in
all groups.
Compared with placebo, glycopyrronium bro-
mide produced significant improvements in dys-
pnea and health status and significantly reduced
the risk of moderate-to-severe COPD exacerba-
tions (p=0.001) and the use of rescue medica-
tion (p=0.039). Glycopyrronium bromide and
tiotropium were comparable for all outcomes vs
placebo. [Eur Respir J 2012;40:1106-1114]
Glycopyrronium bromide significantly in-
creased mean cycling exercise time and im-
proved leg discomfort and exertional breath-
lessness compared with placebo in the smaller
GLOW 3 trial, which involved 108 patients. [Int J
COPD 2012;7:503-551].
The GLOW 5 study recently compared gly-
copyrronium bromide with tiotropium in 657 pa-
tients with moderate-to-severe COPD. After 12
weeks, both treatments showed similar efficacy
and safety, but a faster onset of action on the
first day was seen with glycopyrronium bromide.
[BMC Pulmonary Medicine 2014;14:4]
Dosing and adverse effects
The recommended dosage of glycopyrroni-
um bromide (NVA237) is the once-daily inhala-
tion of the content of one 50 g capsule using
a suitable inhaler. [Seebri Breezhaler Product
Monograph, Novartis, 12/2013]
A P R I L 2 01 4 DRUG PROFILE 27
The results from the pivotal GLOW trials sug-
gest that NVA237 is safe and well tolerated.
[Ther Clin Risk Manag 2013;9:341-353, BMC
Pulmonary Medicine 2014;14:4]. The adverse
effects of NVA237 are typical of an inhaled an-
timuscarinic agent, the most common being
dry mouth, nasopharyngitis, insomnia and gas-
troenteritis. Like other anticholinergic drugs,
NVA237 should be used with caution in patients
with narrow-angle glaucoma or urinary reten-
tion. [Seebri Breezhaler Product Monograph,
Novartis, 12/2013]
Future directions
There is a growing focus on a strategy of
maximal bronchodilation in patients with COPD,
since a single bronchodilator may not be ad-
equate for many individuals. At the present
time, more studies are needed to clarity when
to initiate a combination therapy of drugs from
different classes. However, there is growing evi-
dence that combination therapies of LAMAs and
long-acting beta2-agonists (LABAs) are more
efficacious in improving trough FEV1, dyspnea,
quality of life, and use of rescue medication than
these agents used alone. [Ther Clin Risk Man-
ag 2013;9:341-353, Respir Med 2010;104:995-
1004]
At the present time, there are several new
LABA/LAMA combinations in development
and being studied for use in the management
of COPD. [Expert Rev Respir Med 2012;6:285-
299]

10th Asian-Pacific Congress of Hypertension, February 12-15, Cebu City, Philippines
Hypertension and the Asia Pacific
region
DR. MARIA KATRINA FLORCRUZ
C ardiovascular disease remains one of the
leading causes of mortality in the Philip-
pines. Dr. Rafael Castillo, during his presiden-
tial lecture delivered at the 10th Asian-Pacific
Congress of Hypertension last February 12
to 15 in Cebu City, likened hypertension to a
storm surge. Every year, close to 120,000 Filipi-
nos die due to complications related to hyper-
tension. Non-optimal control of blood pressure
imposes a huge socioeconomic burden as it
causes disruption of work, family and social re-
lationships.
Hypertension in the Asia Pacific region
The latest survey conducted by the Council on
Hypertension of the Philippine Heart Association
showed that the prevalence of hypertension in the
country increased from 17 percent to 28 percent
over the last 10 years. The treatment and con-
trol rates may have improved but that means that
we still have a lot of patients who remain undiag-
nosed [and] who remain untreated, remarked
Castillo.
Globally and in the [Asia Pacific] region, car-
diovascular disease still remains to be the lead-
ing cause of mortality. And there seems to be no
sign that were making any significant progress
in calming the tide of cardiovascular disease.
A P R I L 2 01 4 CO N F E R E N C E COV E R AG E 28
Thats why we call it a storm
surge. And that means that
we have to address it with a
serious sense of urgency,
said Castillo.
He then encouraged Asia-
Dr. Rafael Castillo
Pacific countries to have a
shift in health infrastructure and national poli-
cies towards prioritizing cardiovascular diseas-
es. Globally and in the Asia Pacific region, the
forecast is that we will have more hypertensives
by the year 2025. It is expected that there will be
a 50 to 65 percent increase in the hypertensive
population in the region, he noted.
Castillo cited studies which show that Asians
may be at a greater risk of hypertension-related
complications, such as strokes or cerebrovas-
cular complications, compared to Caucasians.
[Hypertension 2007; 50:991-997] In another
study, Asian patients develop more hemorrhag-
ic strokes compared to Caucasians. The latter
may develop more coronary artery disease.
[Hypertension 2007; 25:73-79] This may in
turn lead to a permanent or complete disability
which implies a serious socio-economic bur-
den.
Compounding the problem of hypertension
in Asia Pacific is the problem of overweight and
obese patients who experience twice the com-
plications of hypertension.

Effective hypertension management
Several barriers affect the management of
hypertension. One of these is the high incidence
of cough with angiotensin-converting enzyme
inhibitors (ACEi) among Asians, compared to
Caucasians, Blacks or Hispanics. In China, the
incidence of cough can be as high as 50 per-
cent, said Castillo.
Managing hypertension in a low-resource
setting is also a challenge as the society has to
address an ideal control strategy. This is a chal-
lenge... when the resources are scarce, we have
to be able to identify those who are high-risk to
develop complications so that we can prioritize
treatment of these patients, said the speaker.
Simple risk assessment tools are be-
ing developed and may help identify high
risk patients without the need for expen-
sive laboratory tests. This way, patients
who need treatment can be identified and
prioritized.
The 24-hour ambulatory blood pressure mon-
itoring may also not be feasible in low-resource
settings where there are problematic cases of
hypertension. As an alternative, Castillo sug-
gested the use of home blood pressure moni-
toring. This can be done by two consecutive
seated measurements at least 1 minute apart
using either a manual or a digital sphygmoma-
nometer. The blood pressure reading can be
taken twice daily for a week. This monitoring will
help the physician arrive at the average blood
pressure, ruling out white coat hypertension in
the process.
The control of salt intake was described by
Castillo as one important intervention which will
A P R I L 2 01 4 CO N F E R E N C E COV E R AG E 29
not cost much but will significantly help control
the blood pressure. Based on Japans experi-
ence, decreasing the daily salt intake from 26
grams to 12 grams per day reduced the systolic
blood pressure by 18mmHg in both genders.
Stroke rates were also reduce by 83 percent.
[APSH Workshop, 2007]
There is a direct relationship between stroke
mortality rate and the level of sodium measured
by urinary excretion as grams of salt per day. Its
not only for stroke but CHD events and all-cause
mortality [which] can be significantly reduced
by salt intake, said Castillo.
The Japanese approach is doable, noted
Castillo, but it requires time. The integrative ap-
proach include intensive and sustained public
education, food delivery system, refrigeration,
exposure to global eating habits, and provision
for low-salt alternatives. [APSH Workshop, 2007]
Eighty-percent of a persons salt intake
comes from packaged and restaurant food and
only about 10 percent comes from the salt add-
ed during cooking. Castillo said that the Food
and Drug Administration (FDA Philippines) can
try to require manufacturers to indicate on their
product labels the amount of sodium. This way,
consumers can have informed choice.
The polypill may also benefit patients with
hypertension. These are safe, inexpensive and
easily dispensed, requiring minimal follow-up.
This is one tool that companies with scarce fi-
nancial resources can utilize. [Using submaxi-
mal doses of a few antihypertensives] might be
better than maximizing the dose of one antihy-
pertensive drug and that can favorably impact
the decreased coronary hearts disease events

and strokes in hypertensive patients, said Cas-
tillo.
The multifaceted preventative and treatment
programs for hypertension control include inten-
sified lifestyle interventions, reduction of salt in-
take by 50 percent, increased potassium intake,
decreased saturated fat intake and increased
physical activity. Aside from individual patient
education, Castillo stressed the importance of
involving the community and its leaders, the
food industry and the law-making bodies.
A vision for Asia Pacific
The vision of the Asia Pacific Society of
Hypertension is to decrease the prevalence of
hypertension and significantly reduce the dis-
A P R I L 2 01 4 CO N F E R E N C E COV E R AG E 30
ease burden caused by hypertension and relat-
ed complications. There must be strong political
and social will as well as population interven-
tion. Patients must be treated holistically for car-
diovascular risk reduction.
Castillo encouraged physicians to become
facilitators for change, playing an active role in
integrating multisectoral strategy for individual,
community and population control of hyperten-
sion.
We may not be able to solve the entire prob-
lem completely by ourselves but we can take
the initiative to serve as the catalyst, to move
everyone to rally behind the cause and goal
of controlling hypertension in the population,
concluded Castillo.
 A P R I L 2 01 4 CO N F E R E N C E COV E R AG E 31

10th Asian-Pacific Congress of Hypertension, February 12-15, Cebu City,

Philippines

Dietary management to control

hypertension
DR. MEL BELUAN

D ietary Approaches to Stop Hypertension

(DASH) is a highly effective aspect of the
non-pharmacologic management of hyperten-
sion. Based on a research sponsored by the US-
based National Heart, Lung and Blood Institute,
it targets hypertensive as well as normotensive
individuals at risk for hypertension.
According to Dr. Nelson Abelardo, professor
with the University of the Philippines, College
of Medicine, DASH involves eating a balanced
diet of low-salt, nutrient-rich, low-cholesterol,
low-saturated-fat food. It calls for a number of
daily servings of different food items, such as
four to five servings of fruits and six to eight
servings of grains, among others.
DASH can be adjusted to suit the daily calor-
ic intake ranging from 1,600 to 3,100 calories.
For a 2,100-calorie daily diet, it recommends
obtaining 27 percent of the daily calories from
fat (of which 6 percent of the total daily allow-
ance is from saturated fat), 15 percent from Canadian Recommendation for Hypertension
proteins and 55 percent from carbohydrates. suggests 1,500mg for ages 50 and younger;
The recommended daily cholesterol is 1,300mg for ages 51 to 70, and 1,200mg for
150mg; fiber 30g; potassium 4,700mg, calcium ages older than 70.
1,250mg, and magnesium 500mg. The daily al- Abelardo cited several studies demon-
lowance for sodium is 2,300mg but 1,500mg strating the impact of diet and other lifestyle
was tested to be even more effective. The 2014 changes on hypertension. The Exercise and

Nutritional Interventions for Cardiovascu-
lar Health study showed that DASH, togeth-
er with exercise and weight loss, resulted in
large improvements in blood pressure (BP)
and cardiovascular functions [Arch Intern Med
2010;170(2):126-35].
In another study, supplementation with poly-
unsaturated fatty acids was linked with reduced
BP, pulse pressure and basal heart rate [Clin
Exp Hypertens 2010;32(2):137-44]. Meanwhile,
the European Prospective Investigation into
Cancer and Nutrition study showed that many
aspects of the Mediterranean diet have ben-
eficial effects on cardiovascular diseases [Am
A P R I L 2 01 4 CO N F E R E N C E COV E R AG E 32
J Clin Nutr 2004;80:1012-18]. In still another
study, gazpacho, a tomato-based cold soup,
was inversely associated with BP and hyper-
tension prevalence. [Nutr Metab Cardiovasc
Dis 2013;23(10):944-52].
Abelardo concluded that based on these
studies, consumption of food rich in antioxi-
dants, healthy fat and minerals (ie, potassium,
magnesium and calcium) vegetables, fruits,
olive oil and seafood can reduce cardiovas-
cular risk. On the other hand, he said, factors
that are positively correlated with BP include
high intake of ethanol, cereals, and meat and
meat products.
 A P R I L 2 01 4 CO N F E R E N C E COV E R AG E 33

10th Asian-Pacific Congress of Hypertension, February 12-15, Cebu City,

Philippines

Can stem cells treat hypertension?

DR. NICOLO CABRERA

W ith prominent personalities swearing by

stem cells, physicians must keep a close
eye on this novel treatment modality. During the
10th Asia-Pacific Congress of Hypertension, Dr.
Eva Maria Cutiongco-dela Paz of the Philippine
Genome Center and the Institute of Human Ge-
netics at the National Institutes of Health brought
physicians up to speed on the basic science on
stem cells and how it may be applied to hyper-
tension.
Stem cells are distinct non-specialized cells
that can replicate and create multiple identical
copies of themselves. They also retain the abil-
ity to develop into various specialized cell types.
Embryos and fetuses are obvious sources of
stem cells but are hounded by ethical concerns.
Alternatively, stem cells may be sourced from
amniotic fluid, placenta or umbilical cord. Most
recently, adult somatic cells may be induced
to become pluripotent stem cells (ie, induced
PSCs or iPSCs), making them among the least
ethically controversial manner of harvesting plu-
ripotent stem cells.
Despite all the excitement, Cutiongco-dela
Paz advocates a cautious approach to stem
cell therapy. [W]e should all recognize that at
the present time... [stem cell therapy] has been
established as a clinical standard of care for
some conditions such as hematopoietic stem
Ongoing research is evaluating the potential of stem cell
treatment in patients with hypertension.
cell transplants for leukemia, epithelial stem
cell-based treatments for burns and corneal
disorders and some rare immune deficiencies.
Published clinical evidence has been unable to
support the use of these therapies for routine
disease treatment.
With respect to cardiovascular disease in gen-
eral, Cutiongco-dela Paz determined that there
are many ongoing clinical trials for the use of
stem cells for heart failure, angina and cardiomy-
opathy. However, as some are not randomized,
findings must be received with a grain of salt.
The potential use of stem cells to treat hyper-
tension is also being studied since damaged en-
dothelial cells are usually replaced by stem cells
mobilized from the marrow that convert into en-
dothelial progenitor cells. In early hypertension,

an increase in circulating endothelial progeni-
tor cells has been documented even with good
blood pressure control.
Angiotensin has also been shown to reduce
telomerase activity and accelerate senescence.
Consequently, giving hypertensive cats cande-
sartan, an angiotensin II receptor antagonist,
restored the number and function of progenitor
cells. Humans given angiotensin-converting en-
zyme inhibitors showed improved function and
Hypertension and dementia: Is there
a link?
DR. JAMES SALISI
T he age at which one acquires hypertension
may matter on the risk of dementia later on,
with mid-life hypertension shown to be associ-
ated with late-life dementia.
Although the association between hyperten-
sion in later-life and cognitive impairment is not
consistent, hypertension contributes to both ear-
ly cerebrovascular brain damage and cognitive
decline, according to Dr. Mohammad Kamran
Ikram from Memory, Aging & Cognition Center
at the National University of Singapore.
Dementia is a multi-factorial disease. It is
a clinical syndrome whose main features are
a progressive, global deterioration in cognitive
function in which memory is especially affected.
An important distinction from delirium is that
there is a clear state of consciousness in pa-
A P R I L 2 01 4 CO N F E R E N C E COV E R AG E 34
increased number as well.
The exact role of these progenitor cells in hy-
pertension has not been sufficiently elucidated,
but in the future these may be targets of future
treatment options for the disease. Cutiongco-
dela Paz, while eagerly awaiting the develop-
ment of the research, also puts the excitement
into perspective, We should all keep in mind,
however, that the use of stem cells in hyperten-
sion is still in its infancy.
tients and one of the decisive features is that it
interferes with social and occupational function
of a certain person, Ikram said.
Diagnosing dementia is a two-step process:
the clear identification of dementia syndrome
followed by the search for etiology or specific
disease syndrome. Ikram distinguished be-
tween dementia and the physiologic decline in
memory and rate of information processing as
people age which does not affect daily func-
tion and significantly worsen.
Alzheimers disease is the most common
cause of dementia, followed by vascular dis-
ease. In Alzheimers disease, a patient may ex-
perience amnesia, aphasia, apraxia, agnosia,
behavioral and psychiatric symptoms such as
psychotic features, personality change and ac-
tivity disturbance. The prevalence and incidence
of dementia increase exponentially with increas-
 A P R I L 2 01 4 CO N F E R E N C E COV E R AG E 35

ing age. late-life cognitive impairment. Among different

The risk factors for dementia include nutri-
tion, cognitive reserve, genetics and cardiovas-
cular disease. A host of factors is involved in
dementia. So, basically it is not a disease with
one component. It is a disease with multiple
component causes and what makes it worse is
that there is a lot of fuzziness in these risk fac-
tors which give you the dementia syndrome,
Ikram explained.
Several big studies on hypertension and de-
mentia have been conducted. The Goteburg
study showed that blood pressure (BP) at age
70 years is related to onset of dementia at 79
to 85 years. The Honolulu-Asia Aging study
showed that mid-life blood pressure is linked to
BP components, systolic BP appears to be the
strongest predictor of cognitive decline.
The pathologies that underlie the mecha-
nisms for the link between hypertension and
cognition include white matter changes, lacunar
infarcts, microinfarcts, microbleeds and macro-
bleeds. Amyloid- peptide accumulation and
synaptic toxicity are neurodegenerative chang-
es also related to hypertension.
The association of hypertension with demen-
tia has led scientists to explore the impact of an-
tihypertensive treatment on dementia later on.
However, meta-analysis has not clearly shown
the positive impact of treatment on outcomes.

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10th Asian-Pacific Congress of Hypertension, February 12-15, Cebu City,

Philippines

BP measurements, while not always

reliable, still yield valuable information
RADHA CHITALE

B lood pressure measurements, in spite of

their potentially variable and unreliable
nature, provide valuable information about car-
diovascular disease and other complications of
high blood pressure (BP), said an expert from
Australia.
It is often out of one reading that deci-
sions are made, [which] are minor representa-
tions of what your blood pressure is, but par-
adoxically these decisions have led to major
advances in the management of people and
prevention of death, said Professor Trefor
Morgan, of the Department of Medicine and
Physiology at the University of Melbourne. evates the SBP, but to a level that may still be
Taking blood pressure measurements cor- below the cutoff for disease.
rectly and under controlled conditions can help More measurements such as ambulatory BP
guide treatment in individuals. But typically, and home BP can round out measurements in
blood pressure is taken in one or two random the clinic and reduce inaccuracy. A Japanese
measurements, which often determine how a study of 1,360 adults in a rural community who
patient is treated, whether it is an acute or long- underwent 24-hour BP monitoring and home
term issue. BP measurements followed up for 10.6 years
It is clear in the elderly, Morgan said, that sys- showed that these measures were useful for
tolic blood pressure (SBP) should guide thera- adding predictive cardiovascular disease (CVD)
py. However, it is less clear in younger people information. [J Hypertens 1997;15:357-364]
because of variability in diastolic blood pressure Tracking night and sleeping BP had predic-
(DBP). When a younger person has hyperten- tive value for vascular complications including
sion, DBP is elevated, which automatically el- ischemic stroke, ischemic heart disease and

other heart disease. Daytime BP, on the other
hand, had superior predictive value for hemor-
rhagic stroke.
Still, people do not develop cardiovascular
damage at the same rate, Morgan said.
Some people will have very high blood pres-
sure and never get complications. Others with
relatively normal blood pressure might develop
left ventricular heart disease.
Certain conditions can cause changes in
A P R I L 2 01 4 CO N F E R E N C E COV E R AG E 38
blood pressure, such as during pregnancy or
in the presence of diabetes and metabolic syn-
drome, when complications can occur at lower
levels of elevated blood pressure.
With all the variations and problems asso-
ciated with blood pressure, let alone the prob-
lems and inaccuracies in measurement, I am
amazed that we have been so successful in
altering the lives of the people that we treat,
Morgan said.
 A P R I L 2 01 4 CO N F E R E N C E COV E R AG E 39

19th World Congress on Controversies in Obstetrics, Gynecology & Infertility

(COGI), 20-23 February, Macau

Monitor offspring of women with GDM,

suggest experts
JACKEY SUEN

E xperts have called for tighter monitoring of

offspring of women with gestational diabe-
tes mellitus (GDM) for any signs of metabolic
syndrome.
GDM management has always focused on
the outcomes of the mother, embryo, fetus and
neonate, said Professor Manuel Carrapato
of the Fernando Pessoa University, Portugal.
There is growing concern that the offspring, at
some stage in adult life, may develop metabolic
syndrome.

The effect of GDM is a vicious

cycle, with consequences for the
offspring extending beyond the
neonatal period

Epidemiological studies have suggested that

the offspring of diabetic mother (ODM) are at
risk of developing obesity, insulin resistance, hy-
pertension or vascular complications later in life.
Early DM surveillance in ODM may be possible,
as we have identified in our study some early
metabolic syndrome-related signs or symptoms
ODM may show in their childhood, said Car-
rapato.
In our study of 254 ODM in Portugal, female
Diabetes during pregnancy may beget diabetes in ones
children.
ODM are already showing a tendency for ex-
cess weight gain and a rise in blood pressure by
school age, he noted. These individuals are at
high risk of metabolic syndrome in adulthood,
and require tight follow-up through childhood
and adolescence.
The effect of GDM is a vicious cycle, with

consequences for the offspring extending be-
yond the neonatal period. Women whose moth-
er had GDM are at risk of perpetuating the cycle
by developing DM in her childbearing years,
said Professor Terence Lao of the Chinese Uni-
versity of Hong Kong. Therefore, GDM has to
be more tightly managed for better maternal, fe-
tal and neonatal outcomes and better long-term
effects on offspring, to break the vicious cycle of
A P R I L 2 01 4 CO N F E R E N C E COV E R AG E 40
DM begets DM.
When dietary and lifestyle modifications fail
to maintain postprandial glucose of <7 mmol/L
or fasting glucose of <6 mmol/L in women with
GDM, insulin injection should be considered,
suggested Lao. Metformin can be used as an
alternative or add-on to insulin therapy, as it is
proven to be safe and effective for GDM manage-
ment, and is more acceptable than insulin.
 Treatment Updates on
Diabetes and Lipid Disorders
Find out what these experts have to say about upcoming
treatments for diabetes and lipid disorders and the risks
related to obesity

Dr John Professor Professor Dr David Professor Professor

Foreyt Christophe Brian Sullivan Jonathan Helena
Lifestyle de Block Tomlinson Effective Shaw Gylling
approaches Risks associated Future therapies therapies for The importance The effective use
to manage with obesity and to treat familial dyslipidemia of glucose of plant sterols
weight loss in the benefits of hypercholes- when statins are control and stanols
obese patients early prevention terolemia and insufficient and associated with in lowering
through exercise difficulties in future treatments cardiovascular LDL-cholesterol
and dietary measuring the in development risk and the and how these
modifications prevalence of safety of DPP4-I products can
this disease in and GLP-1 be used to treat
Asia treatments dyslipidemia

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19th World Congress on Controversies in Obstetrics, Gynecology & Infertility
(COGI), 20-23 February, Macau
Experts call for increased oral
contraceptive use in China
JENNY NG
E xperts are calling for more education to
increase the use of combination oral con-
traceptives (COCs) in China as up to 10 million
abortions are performed each year for unwant-
ed pregnancies.
Over the past 30 years, contraceptive use in
China has changed little, with the percentage of
women using COCs remaining below 2 percent
despite the availability of new products. [China
Government, Health Authorities Data 2010]
Unlike in Europe, more than 95 percent
of COC use in specialized womens hospitals
in China is for the treatment of medical condi-
tions such as polycystic ovarian syndrome or
bleeding, rather than for contraception, said Dr.
Xiangyan Ruan of the Beijing Obstetrics and Gy-
necology Hospital, Beijing, China.
In the future, we can expect an increase in
COC use due to greater information via media
outlets and the internet, but we need more dis-
cussion and more education on the benefits of
COCs and the different options available, said
Ruan.
In China, 363 million women are of reproduc-
tive age, but only about half use some method
of contraception. Of those who do, the majority
A P R I L 2 01 4 CO N F E R E N C E COV E R AG E 42
choose either non-hormonal intra-uterine devic-
es (IUDs, 54 percent in 2010) or sterilization (31
percent in 2010).
This has to do with the availability of free
non-hormonal IUDs offered under the family
planning policy in China. As Ruan suggests, al-
ternative methods such as hormone-releasing
(levonorgestrel)-IUDs and hormonal long-acting
injections and implants, each making up less
than 0.2 percent of contraceptives used, are not
well-understood options for women in China.
COCs have the potential to reduce the num-
ber of unwanted pregnancies while also pro-
viding a number of non-contraceptive benefits,
including reductions in cycle disturbances, dys-
menorrhea, anemia, acne and hirsutism, rheu-
matoid arthritis, as well as risk of breast and
ovarian tumors, which need to be relayed to
both gynecologists and patients.
COC use accounts for around 20-30 percent
of contraceptive use in the US and Europe com-
pared with just 1-2 percent in China and Japan,
said Ruan. These differences may reflect the
differences in opinion of the prescribing doctors
or users, and perhaps more on non-medical rea-
sons such as politics. Compared with Europe,
we see that more knowledge of COCs is needed
in China.

WHOs tribute to women
Dr. Margaret Chan
WHO Director-General
O n this International Womens Day, WHO
joins others in celebrating
achievements. These achievements are inspir-
womens
ing, and they can inspire change.
In health development, as in many other ar-
eas, women are agents of change. They are the
driving force that creates better lives for families,
communities and, increasingly, the countries
they have been elected to govern.
T
 he health sector can do much to
free women by ensuring they have
access to all the health services
they need, including sexual and
reproductive health services 
As I have learned from my discussions with
parliaments in several countries, women are in-
creasingly winning top leadership roles, in rich
and poor countries alike, and this helps shape
entire societies in broadly beneficial ways. Every
time a woman excels in a high-profile position,
her achievement lifts the social status of women
everywhere.
To inspire change, all women need to be free
to achieve their full potential. This means free-
dom from all forms of discrimination, freedom
to pursue all opportunities, including education,
A P R I L 2 01 4 F E ATU R E 43
Women are agents of change and the driving force that
improves health care in the community.
freedom to earn and spend their own income,
and freedom to follow the career paths they
want.
The health sector can do much to free wom-
en by ensuring they have access to all the health
services they need, including sexual and repro-
ductive health services. Participants at last years
London Summit on Family Planning achieved a
breakthrough commitment to halve the number
of girls and women in developing countries who
want modern contraceptives, but who have no
access. This commitment will give 120 million
additional women the right to decide whether,
when and how many children they want to have.
This, too, is freedom.
Throughout history, women have been as-
sociated with care and compassion. Worldwide,
up to 80 percent of healthcare is provided in the
home, almost always by women. This should
inspire our admiration, but it should also under-
 A P R I L 2 01 4 F E ATU R E 44

score the need for change. Most of this work is
unsupported, unrecognized and unpaid.
Polio is on the verge of eradication, largely
thanks to the millions of women from vacci-
nators to administrators to medical doctors and
mothers who have made vaccination and pro-
On this International Womens Day, let me
thank these women for a level of dedication
that can improve the world in a permanent
way.
Source: WHO [Available at: www.who.int/mediacentre/news/state-

tection of children their lifes mission. ments/2014/international-women-day/en/Accessed on 11 March]

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 A P R I L 2 01 4 C A L E N DA R 45

50th American Society of Clinical

Sit for the Part 1 of the Oncology (ASCO) Annual Meeting
30/5/2014 to 3/6/2014
Location: Chicago, Illinois, US
AUSTRALIAN MEDICAL COUNCIL EXAMS Info: ASCO
Tel: (1) 571 483 1599
MCQ Email: meetings@asco.org
Website: www.asco.org
Commences 23rd April 2014 in Kuala Lumpur
UPCOMING
Fast Track 5 week intensive Course (100% passes for previous students) European Society for Pediatrics,
Lecturers will be flying in from Australia. Hepatology and Nutrition
Total cost: AUS $ 3,950.00 (ESPGHAN) 47th Annual Meeting
9/6/2014 to 12/6/2014
Full details on the exam is explained on the AMC website: www.amc.org.au
Location: Jerusalem, Israel
Info: MCI UK Limited
Coordinator: Mr. Ganson Govender Local Contact: Mr. Palani Murugappan
Mobile: +61- 414 546 561 (Australia) Mobile: +60-12-212-5422 Tel: (44) 0 845 1800 360
Email: gansong2@gmail.com Email: palani@avimursolutions.com E-Mail: ESPGHAN2014-Reg@
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U R L : w w w. G r a d A u s m e d . c o m Website: www.espghan2014.org/
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APRIL European League Against

29th Annual European Association
Rheumatology (EULAR) 2014
WCO-IOF-ESCEO World Congress of Urology (EAU) Congress
11/6/2014 to 14/6/2014
of Osteoporosis 11/4/2014 to 15/4/2014
Location: Paris, France
2/4/2014 to 5/4/2014 Location: Stockholm, Sweden
Info: EULAR Secretariat
Location: Seville, Spain Info: EAU
Tel: (41) 22 33 99 590
Info: Yolande Piette Communication Tel: (31) 26 389 06 80
Website: www.eular.org/index.
Tel: (32) 4 254 12 25 Email: info@uroweb.org
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Email: info@piettecommunication.com
Website: www.wco-iof-esceo.org MAY 20th ASEAN Federation of
Cardiology Congress 2014
American Association for Cancer World Congress of Cardiology 12/6/2014 to 15/6/2014
Research (AACR) Annual Meeting (WCC) Scientific Sessions 2014 Location: Kuala Lumpur, Malaysia
5/4/2014 to 9/4/2014 4/5/2014 to 7/5/2014 Info: AFCC Secretariat
Location: San Diego, California, US Location: Melbourne, Australia Tel: (60) 3 7955 6608
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Website: www.aacr.org Website: www.world-heart-federation.org
19th Congress of the European
21st Regional Conference of 7th World Congress of the World Association of Hematology
Dermatology (RCD) 2014 Institute of Pain (WIP) 12/6/2014 to 15/6/2014
9/4/2014 to 12/4/2014 7/5/2014 to 9/5/2014 Location: Milan, Italy
Location: Danang, Vietnam Location: Maastricht, Netherlands Info: EHA Organizing Committee
Info: Congress Administration Info: WIP 2014 Registration Department Tel: (31) 0 70 3020099
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Website: http://asianderm.org/21rcd/ Pages/Home.aspx
congress/key-information/
index.htm

Photos courtesy of Tom Woods
TOM WOODS
P hnom Penh offers a convenient option
for people looking for a short city break
in Southeast Asia. With a growing number of
flights linking the city to other hubs in the re-
gion, and online visa services for those who
need them, it is a convenient and very inter-
esting city to explore for a few days.
For a visitor arriving in Phnom Penh by
plane, the first things to hit you are the heat
and dust. The dry heat seems more intense
than Singapore or Bangkok and the dust is
plentiful. The shops you pass on the way
from the airport into the city have all their
A P R I L 2 01 4 A F TE R H O U R S 46
goods covered with sheets of plastic to pro-
tect them from the thick red dust. Another
initial impression is that this is a city on the
rise. There are new buildings and struc-
tures being constructed and several major
improvements to the road infrastructure
happening across the city to help ease the
traffic jams. These works and the number
of people constantly on the roads make it a
very busy place. And it will only get busier;
children seem to be everywhere. Every adult
lap seems to be furnished with a baby and
the country has one of the highest birth rates
in Asia.
There are lots of foreigners in Phnom

Penhnot just people on holiday, but peo-
ple investing in property and new business-
es, working for NGOs, and quite a number
teaching English. A lot of Cambodians, too,
seem to be doing very well out of the boom
times in the city. However, a huge wealth dis-
parity is obvious. There are poor street kids
and people living in extreme poverty on the
streets, alongside huge numbers of very luxu-
rious cars. Range Rover must love Cambo-
dia; I have never seen so many of them in
one place.
This is a city vibrant with contrasts old
and new, young and old, rich and poor, the
packed backstreets crammed around the
wide French boulevards. And it is never
more apparent than when considering the
promise of the city in the present and the
horrors of its past.
As a tourist and really, as a human being,
one of the main things to do in Phnom Penh
is to find out more about the Khmer Rouge.
Youll be offered tours from every tuk-tuk
driver, and at any hotel or guesthouse you
stay at. The Khmer Rouge, led by Pol Pot,
was responsible for a horrific genocide they
inflicted on their own people. In the 4 years
from 1975 to 1979, it is estimated that 2 mil-
lion people were killed, out of a total popula-
tion of 8 million. Two main sites that chronicle
this atrocity are the Killing Fields and S-21, a
prison. Both of these are museums and me-
morials. A good read prior to visiting is First
They Killed my Father, by Loung Ung, which
A P R I L 2 01 4 A F TE R H O U R S 47
explains the Khmer Rouge regime though
the eyes of a young girl.
Tuol Sleng Genocide Museum, better
known simply as S-21, is the first stop. It was
a school before the Khmer Rouge took con-
trol of Cambodia in 1975. It was converted
into a notorious prison which housed 20,000
people. Only seven survived. The rooms dis-
play rows upon rows of photos of the victims
who were sent here. It is harrowing to look
into their unblinking faces, and especially to
consider the number of children sent there
for political crimes who faced a terrible end
to their lives.
Tours will usually then drive you out to the
Killing Fields, about 15km from the city cen-
ter. This site houses a memorial, museum
and a skull-filled stupa which commemorate
the people who died there, and in the 308
other mass grave sites that have been found
across Cambodia. An audio tour is available,
and recommended to get a better under-
standing of what happened there.
The tour ends with the same warning as
the museum at Auschwitz; this memorials
purpose is to remind people of what hap-
pened so they can ensure it doesnt happen
again. They are both worth visiting. Much
like visiting World War II concentration camp
memorials, though, these visits will leave
you contemplating the terrible things we do
to each other.
However, if that doesnt appeal there is a
lot more to Phnom Penh today than these

tragic reminders. There is a lot to see of its
ancient history. Visit the Royal Palace where
the king still resides. It is filled with temples,
including the extravagant Silver Pagoda,
decorated with 5 tons of silver and Italian
marble. It is a very tranquil place to spend a
few hours away from the bustle of the streets
outside. A stroll down the river front will lead
you to the National Museum which is set in
lovely gardens and inside a sandstone build-
ing, built in 1917 in the Khmer style.
Sisowath Quay on the Tonle Sap riverfront
is great for an evening amble. Grab a drink
at the iconic Foreign Correspondents Club,
especially popular during their happy hour
between 5pm and 7pm. There is some great
food available nearby too. A mix of Khmer,
Thai, Vietnamese and Indonesian, with nu-
merous Western and especially French-in-
A P R I L 2 01 4 A F TE R H O U R S 48
fluenced options too. These can range from
street carts to fine dining, all at very reason-
able prices. New restaurants, bars and cof-
fee shops are opening constantly. A must
try is baguette served with pate and a few
pickles. They are available all over town from
little shops or vendors.
The impressive central market is a huge
1930s Art Deco dome structure, and well
worth a visit. It houses organized rows of a
wide range of goods, from fish to furniture.
You may also wish to pop across to the Rus-
sian market for a shopping and bartering ad-
venture.
Phnom Penh is a rapidly changing city.
While there are obvious problems from pov-
erty to traffic snarls visitors will take plenty
away from the sheer energy of the place and
the positive attitude of its people.
 A P R I L 2 01 4 H U MO R 49

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Medical Tribune is published 12 times a year (23 times in Malaysia) by MIMS Pte Ltd. Medical Tribune is on
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Philippine edition: Entered as second-class mail at the Makati Central Post Office under Permit No. PS-326-01
NCR, dated 9 Feb 2001. Printed by KHL Printing Co Pte Ltd, 57 Loyang Drive, Singapore 508968.

ISSN 1608-5086