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8/10/2019 Medical Tribune December 2014 REG
1/33
DECEMBER 2014
FORUM
Funding forsmoking cessation
campaigns disclosures matter
FEATUREEmerging trends
in preeclampsia
DRUG
PROFILE
Inhaled fluticasonefuroate /vilanterol for the
management of
stable COPD
CONFERENCE
COVERAGE
Making a casefor adiponectin in
diabetes and its
complications
Audiovisual aidsan effective learning tool
for new parents
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DECEMBER 2014 2
LIANNE COWIE
Interactions with caregivers during the first fewyears of life are crucial for the psychosocialdevelopment of children, and programs aimed
at promoting parent-child interactions can be an
important tool for modifying parental knowledge
regarding effective care practices.
A recent study showed that early exposure to
an audiovisual aid (when the infant was 1 month
of age) altered parental knowledge regarding
such practices, whereas exposure at a later
point (age 7 months) altered parental attitudes.
[BMC Paediatrics2014;14:222]
Our results support the idea that audiovisual
materials, if properly designed and adminis-
tered, can be an effective complementary tool
in programs aimed at supporting parents, par-
ticularly when dealing with their first baby, said
the study authors, led by Dr. Anna Roia, Institute
for Maternal and Child Health, IRCCs Ospedale
Infantile Burlo Garofolo, Trieste, Italy. They also
provide useful insight about the different ben-
efits of using such visual aids at different times
during the first year of the baby.
The researchers contacted a convenience
sample of 127 families living in the area imme-
diately after birth while the mother and infant
were still in the maternity ward. Of the families
who agreed to participate, 53 were randomly as-
signed to the early intervention group and 52 to
the late intervention group.
The intervention
consisted of a video
addressing four spe-
cific activities related
to early child develop-
ment: reading aloud to
the baby, early expo-
sure to music, and pro-
motion of early social-
ization for the parents
and their children. The
video was delivered
via a home visit by a
psychologist. Ninety-nine families (52 in the ear-
ly and 47 in the late group) completed the study.
Parents in the early intervention group more
frequently reported modification of their knowl-
edge relating to the importance of early reading
aloud and infant socialization. Parents in the late
intervention group more frequently reported the
acquisition of positive attitudes towards early
reading aloud, early exposure to music, and pa-
rental socialization.
[T]he importance of an appropriate setting
of administration, ideally through a home visit as
in our study, cannot be overlooked, concluded
the authors. This aspect may be even more
important when dealing with population groups
which, due to specific cultural or social reasons,
are more difficult to reach out to and yet are
those that would yield the greatest benefit from
such interventions.
Audiovisual aids an effective
learning tool for new parents
A recent study supportsthe use of audiovisualprograms for new parents.
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DECEMBER 2014 3
ELVIRA MANZANO
Anew guideline from the American Collegeof Physicians (ACP) recommends increas-ing fluid intake for patients who have had kidney
stones, and pharmacotherapy if increased fluid
alone is inadequate, to prevent stone recurrence.
Increased fluid intake spread throughout the
day can decrease the stone recurrence by at
least half with virtually no side effects, said Dr.
David A. Fleming, ACP president.
The goal for increasing fluid intake is to im-
prove urine output to a minimum of 2L a day. For
patients who fail to reduce stone formation de-
spite this approach, monotherapy with a thiazide
diuretic, citrate, or allopurinol may be considered.
[Ann Intern Med2014;161:659-667]
The evidence for both recommendations was
classified as low to moderate quality.
Kidney stones (nephrolithiasis) form when
crystals or substances that are normally pres-
ent in the urine become highly concentrated,
said guideline author Dr. Amir Qaseem from
the University Health System of Pennsylvania in
Philadelphia, Pennsylvania, US. In most cases,
the stones consist of calcium oxalate and/or cal-
cium phosphate, or other substances such as
uric acid, struvite, and rarely, cystine. The lifetime
prevalence of kidney stones is 13 percent in men
and 7 percent in women. Five-year recurrence
rate can reach up to 50 percent, if left untreated.
The guideline is based on published studies
on kidney stones from January 1948 through
March 2014. The clinical outcomes evaluated
for the guideline were symptomatic stone recur-
rence, pain, urinary tract obstruction with acute
renal impairment, infection, procedure-related ill-
ness, emergency department visits, hospitaliza-
tions, quality of life, and end-stage renal disease.
Intake of fluids was one of the dietary interven-
tions evaluated.
In one study, patients with calcium stones
who increased their fluid intake to achieve >2L
of urine per day had less composite stone re-
currence within 5 years compared with the
control group (12.1 versus 27 percent). [J Urol
1996;155:839-843] Another study showed that
increased fluid intake resulted in a non-statisti-
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]
The authors, however, cautioned that drink-
ing extra fluids may not work for some patients
with kidney stones. It is also contraindicated in
heart failure patients. With regard to pharma-
cologic treatments, combination therapy with
a thiazide diuretic, citrate or allopurinol was no
more beneficial than any of these agents taken
alone. Some of the adverse effects associated
with these drugs included fatigue, gastrointesti-
nal problems, headache and anemia.
New guideline for preventing kidney
stone recurrence
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DECEMBER 2014 FORUM 4
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
Akey challenge faced by anti-smoking bod-ies is that there is a lack of funds for theircampaigns. There is still a lack of awareness of
the risk factors associated with tobacco smok-
ing, and smoking in general is often viewed as
an issue of personal behavior, which is inaccu-
rate, said Dr. Carolyn Dresler, associate direc-
tor for Medical and Health Sciences in the Office
of Science at the US FDA Center for Tobacco
Products Office. Its not just a behavioral prob-
lem were dealing with; its a chemical addiction
nicotine addiction which is a serious disease.
With regards to the relationship between
the pharmaceutical industry and smoking ces-
sation, to me it depends a little on the duplicity
of the industries involved, said Dresler. In my
opinion, the tobacco industry are convicted liars,
but we cannot ignore that the pharmaceutical in-
dustry has had similar issues. However, the mis-
sion of pharmaceutical companies is ostensibly
for good, whereas the product produced by the
tobacco industry, when used as indicated, kills.
Dresler noted that she was a former medical
director of research and development for NRT
products at a leading pharmaceutical company.
Market forces at play
It is true that both smoking as well as smok-
ing cessation are driven by market forces, said
Dresler, highlighting a recent case in which a US
District Court in Washington D.C., ruled against
the US FDA in favor of cigarette makers Loril-
lard Inc and Reynolds American Inc, who had
sued the FDA in 2011, alleging conflicts of inter-
est and bias by several members of the panel
tasked with advising the FDA on tobacco-relat-
8/10/2019 Medical Tribune December 2014 REG
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DECEMBER 2014 FORUM 5
ed issues. Their lawsuit specifically alleged that
some committee members had conflicts of in-
terest as they were paid expert witnesses, and
possessed financial ties to pharmaceutical com-
panies that manufactured smoking-cessation
products.
In his ruling, which took place in July 2014,
US District Judge Richard Leon said the FDA
had erred in determining that the members did
not have conflicts of interest and therefore, the
agencys appointment of those members was
arbitrary and capricious, and tainted both the
panel and its work. The FDA was ordered to
reconstitute the tobacco panel and the use of
its 2011 report on menthol cigarettes has been
barred. [Available at https://ecf.dcd.uscourts.
gov/cgi-bin/show_public_doc?2011cv0440-82.
Accessed on 13 December 2014]
It is difficult to separate conflict of interests
and biases from something like smoking cessa-
tion, especially when theres funding involved,
Dresler admitted. This is because, as I men-
tioned, there is already very little funding being
allocated for smoking cessation campaigns,
said Dresler. When you put it up against some-
thing as large as the tobacco industry, with their
large resources, and their ability to influence
government and political decisions, its an uphill
battle.
Is there an ideal source of funding?
If you have sources of funding from non-
pharmaceutical organizations, such as non-gov-
ernmental organizations or the health ministry,
that would be best, said Associate Professor Dr.
Mohamad Haniki Nik Mohamed, Deputy Dean
at Kulliyyah of Pharmacy at the International Is-
lamic University Malaysia. However, given the
limitations, sometimes we do have to consider
accepting funding from pharmaceutical compa-
nies to facilitate certain events. In such cases,
the funding company should not become in-
volved in the planning of the advocacy program
it should be completely independent.
The worst thing to do, he stressed, would
be to accept funding from the tobacco indus-
try, for whatever purpose. Dr. Zarihah Zain of
the Disease Control Disease, Ministry of Health
Malaysia, agrees. According to Article 5.3 of
the Framework Convention on Tobacco Control
(FCTC), parties to the Convention should not
partner with tobacco corporations to promote
public health, nor accept the tobacco indus-
trys so-called corporate social responsibility
schemes, which are really just marketing by an-
other name, she said.
The Article 5.3 Guidelines also outlined trans-
parency measures including, Disclosure of cur-
rent or previous work with tobacco industry by
applicants for government positions related to
health policy, and of plans to work for tobacco
industry by former public health officials. Also,
disclosure of tobacco industry activities, includ-
ing: production, manufacture, market share,
revenues, marketing, expenditures, philanthro-
py with penalties for providing false or mis-
leading information. [Available at www.fctc.org/
media-and-publications/media-releases-blog-
list-view-of-all-313/industry-interference/718-ar-
ticle-53-framework-convention-on-tobacco-con-
trol-tobacco-industry-interference. Accessed on
14 December 2014.]
8/10/2019 Medical Tribune December 2014 REG
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DECEMBER 2014 NEWS 7
Discussing preferences critical
during end-of-life care
RADHA CHITALE
End-of-life care discussions are tricky andnecessary, but a new survey reveals theseconversations are not happening, based on
what patients and their families say their end-
of-life goals are versus what they are advised by
experts. [CMAJ2014. doi:10.1503/cmaj.140673]
Our findings could be used to identify impor-
tant opportunities to improve end-of-life com-
munication and decision-making in the hospital
setting, said lead researchers Dr. John You, as-
sociate professor of Medicine and Clinical Epi-
demiology and Biostatistics at McMaster Univer-
sity in Hamilton, Ontario, Canada.
The current literature regarding end-of-life
care discussions suggests 11 topics that are
considered most important by doctors, with
little to no input from patients or families, the re-
searchers noted.
However, when the researchers surveyed real
patients (mean age 81) and families about which
topics they felt were most important, opinions
converged to identify the following five areas:
- preferences of care in event of life threatening
illness
- patient values (what is important when consid-
ering healthcare decisions)
- prognosis of illness
- fears or concerns
- additional questions regarding care
However, it was clear that halting discussion
there was not necessary. Patient satisfaction
scores were directly proportional to how much
physicians were willing to discuss end-of-life
care. Patient satisfaction improved as they cov-
ered more topics and as the number of times
they had such discussions increased.
The Canada-based survey included 233 el-
der adults in hospital who had serious illnesses
and 205 of their family members.
The researchers found that end-of-life care
discussions occurred in less than one-third of
cases, sometimes as little as 1.4 percent of the
time. This appeared to support national data
showing that rates of cardiopulmonary resus-
citation (CPR), dying in-hospital, and intensive
care unit deaths are rising among elderly pa-
tients with serious disease, despite the fact that
80 percent of these patients prefer a less ag-
gressive and more comfort-oriented end-of-life
care plan that does not include CPR, the re-
searchers said.
Other topics of discussion on the 11-item list
that patients did not identify in their top five in-
cluded facilitating access to legal documents to
record patient wishes and providing information
about the outcomes, risks, benefits of comfort
care. [Med J Aust 2007;186:S77,S79,S83-108;
Advance Care Planning. Concise Guidance
to Good Practice Series, No 12. London (UK),
2009]
8/10/2019 Medical Tribune December 2014 REG
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DECEMBER 2014 NEWS 8
Mental disorders may cause cardiac
symptoms
RADHA CHITALE
Depression, anxiety and other psychologicaldisorders are known to influence cardiacactivity and can result in cardiac symptoms even
when tests show patients to be free of heart dis-
ease.
Despite this high importance, in patients
with non-cardiac chest pain, mental disorders
are often diagnosed too late, because cardiolo-
gists 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
order to determine the extent of the correlation.
About 20 percent of people who suffer from
cardiac symptoms such as chest pain or short-
ness of breath do not have heart disease but
they are just as likely to use healthcare resourc-
es and can have lower quality of life. Early iden-
tification could alleviate this problem.
The trial included 235 patients with at least
one cardiac symptom chest pain (55.3 per-
cent), dyspnea (35.4 percent), or palpitations
(39.4 percent) who were assessed for and
did not have coronary artery disease (CAD).
[Open Heart 2014;1:e000093.doi:10.1136/
openhrt-2014-000093]
These patients were given a questionnaire
that tested for general and heart-related anxiety
and depression, idiopathic pain with a poten-
tially psychological root, hypochondriac ten-
dencies, and quality of life in relation to physical
and mental health before and 6-8 months after
undergoing an invasive coronary angiography.
The test revealed that 8.7 percent of patients
reported severe cardiac symptoms prior to
coronary angiography and 28 percent reported
moderate symptoms.
However, even after CAD exclusion following
angiography, 70 percent of patients reported
persistent symptoms.
Compared to a population of healthy adults,
general anxiety was higher by 37 percent
(p
8/10/2019 Medical Tribune December 2014 REG
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DECEMBER 2014 NEWS 9
by study participants compared to the normal
population.
The researchers noted they were unable to
determine cause and effect between psycho-
pathological symptoms and cardiac symptoms
or vice versa. They also lacked information
about gastrointestinal disorders, skeletal condi-
tions or other non-cardiac causes of chest pain.
However, the study did suggest patients with
non-cardiac chest pain should be offered psy-
chological or psychiatric support early in order
to begin psychosomatic therapy, which may
prevent patients from seeking pharmaceutical
or procedural solutions, and to improve their
quality of life.
Without training, cardiologists are more likely
to overlook psychosomatic symptoms, but the
researchers suggested the 120-minute ques-
tionnaire that takes 15 minutes to evaluate by a
nurse was a practicable solution for inpatients
and outpatients.
These [standardized questionnaires] may
prevent repeated utilization of the healthcare sys-
tem and this could help to reduce costs for these
patients due to initiation of an early psychoso-
matic therapy, the researchers said.
8/10/2019 Medical Tribune December 2014 REG
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DECEMBER 2014 NEWS 10
Neuroticism, long-term stress
linked to higher risk of Alzheimers
in women
ELVIRA MANZANO
Women who worry a lot and cope poorlywith stress may be at an increased risk ofdeveloping Alzheimers disease (AD) later in life,
research suggests.
A study of 800 women in Sweden followed
for 38 years showed that women with the high-
est scores on neuroticism scale and had expe-
rienced long-term distress in midlife were twice
as likely to develop AD than those with the
lowest scores. [Neurology 2014; pii:10.1212/
WNL.0000000000000907;E-pub ahead of print]
Neuroticism is the enduring tendency to be
in a negative emotional state. People with neu-
rotic personality may perceive daily run-of-the-
mill situations as alarming or depressing. They
suffer from negativity, feelings of guilt, anxiety,
envy and anger more frequently and more se-
verely than other people and have difficulty
managing stress, although they are in touch
with reality.
We have shown in this study that midlife
neuroticism is associated with increased risk of
AD, and that distress mediates this association.
Clearly, there was a clear statistical correlation in
those who had been exposed to a long period
of stress, said Johansson. It is the stress itself
that is harmful. A person with a neurotic tenden-
cy is more sensitive to stress than other people,
said lead researcher Dr. Lena Johansson from
the Sahlgrenska Academy at Gothenburg Uni-
versity in Molndal, Sweden.
Using the Eysenck Personality Inventory
scale, women were assessed of their dominant
personality traits (ie, extraversion vs introversion
and neuroticism vs stability). Dementia was di-
agnosed according to DSM-III-R criteria, based
on information culled from neuropsychiatric ex-
aminations, hospital records, and registry data.
During the study period, 153 women who had
neurotic tendencies at midlife had developed
some types of dementia, 104 of which had AD.
Advancing age, family history, and genetics
are known risk factors for AD and other demen-
tia-related disorders. This is the first study to
show a link between personality and AD, said
Johansson. However, the finding does not sug-
gest that neuroticism alone could increase the
risk of AD.
Personality could determine behavior, life-
style and how we react to stress. Ultimately, all
these may significantly affect the risk of develop-
ing AD.
She said future studies should exam-
ine whether this group of women will re-
spond well to interventions. It remains to be
seen whether neuroticism could be modi-
fied by medical treatment or through lifestyle
changes.
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DECEMBER 2014 RESEARCH REVIEWS 11
Reducing 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 multination-
al group of researchers.
In their study, 70 patients (mean age 60.3
years) with radiographically confirmed pain-
ful 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
significant reductions in pain were only ob-
served when patients were using the medial
supported lateral wedge insole (-6.29 per-
cent vs control). However, there was no differ-
ence in pain reduction between patients who
experienced a decrease in EKAM and those
who did not. Moreover, patients who experi-
enced consistent major reductions in EKAM
did not report a consistent reduction in knee
pain.
Jones R et al. The relationship between reductions
in knee loading and immediate pain response whilst
wearing lateral wedged insoles in knee osteoarthritis. J
Orthop Res 2014;32:1147-1154.
Reducing knee load with lateral wedge insoles does not
alleviate knee OA pain
8/10/2019 Medical Tribune December 2014 REG
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DECEMBER 2014 RESEARCH REVIEWS 12
Iodothyronine deiodinases are key regulators
of thyroid hormone metabolism and since
thyroid hormones are functionally active in nu-
merous tissues, deiodinase polymorphisms
have the potential to affect multiple clinical
endpoints.
In a recent systematic review, researchers
evaluated the relationship between iodothyro-
nine 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.
The researchers found that deiodinase type
1 (D1) polymorphisms showed a moderate-to-
strong relationship with thyroid hormone pa-
rameters, insulin-like growth factor 1 produc-
tion, and risk for depression. D2 variants were
correlated with thyroid hormone levels, insulin
resistance, bipolar mood disorder, psychologi-
cal well-being, mental retardation, hyperten-
sion, and risk for osteoarthritis, and one D3
polymorphism was associated with a risk for
osteoarthritis. However, the researchers noted
that the clinical implications of these associa-
tions are far from clear and may vary among
different populations. They commented that
further research is required to determine the
exact role of deiodinase polymorphisms and
their potential as therapeutic targets.
Verloop H et al. Genetic variation in deiodinases: a sys-
tematic review of potential clinical effects in humans. Eur
J Endocrinol 2014;171:R123-R125.
Clinical effects of deiodinase polymorphisms studied
8/10/2019 Medical Tribune December 2014 REG
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DECEMBER 2014 DRUG PROFILE 13
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.
Inhaled fluticasone furoate /
vilanterol for the management
of stable 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
COPD include cigarette smoking, air pollution
(both outdoor and indoor) and occupational
hazards such as vapours, fumes and irritants.
In high-income countries, smoking is the pre-
dominant cause whereas in low-income coun-
tries indoor air pollution associated with the
use of fuels for cooking and heating produces
most COPD burden. [WHO Fact Sheet No 315.
Chronic obstructive pulmonary disease]
COPD is now the fifth-most common cause
of death worldwide and total deaths from COPD
are projected to increase by more than 30 per-
cent in the next 10 years.
In Asian countries COPD burden is higher
than in their Western counterparts, with more
deaths, years spent living with disability, and
years of life lost. This can be attributed to high
tobacco smoking rates, poor quality of outdoor
air and the use of biomass fuels indoors. [Int J
Tuberc Lung Dis 2008;12:713-717]
The diagnosis of COPD in symptomatic pa-
8/10/2019 Medical Tribune December 2014 REG
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DECEMBER 2014 DRUG PROFILE 14
tients is made on the basis of spirometry, which
measures the presence and severity of airflow
obstruction: COPD is characterised by airflow
obstruction that is not fully reversible on the
administration of bronchodilators. [Ann Intern
Med2011;155:179-191]
The priorities in management of COPD in-
clude smoking cessation and using effective
inhaled therapy. In patients with stable disease
who remain breathless or experience exacer-
bations despite use of short-acting bronchodi-
lator reliever therapy, guidelines recommend
the use of maintenance therapy. Those with a
forced expiratory volume (FEV) 50 percent of
predicted should be given either a long-acting
beta-2 agonist (LABA) or long-acting musca-
rinic antagonist (LAMA). When FEV falls below
half that predicted, patients should be given
either a LABA with an inhaled corticosteroid
(ICS) in a combined inhaler or a LAMA. [NICE.
Management of chronic obstructive pulmonary
disease in adults in primary and secondary
care. June 2010]
The combination of ICS and LABA in a single
device is well tolerated and results in improved
FEV, quality of life and respiratory symptoms
in stable COPD patients. Over time, there have
been progressive improvements in available
LABA and ICS therapies, allowing the develop-
ment of treatment delivered in once-daily, sin-
gle device format. [Int J COPD2014;9:249-256]
Fluticasone furoate / vilanterol
Mode of action
Fluticasone furoate is a corticosteroid with
anti-inflammatory activity. It is highly potent,
binding more strongly to the glucocorticoid re-
ceptor than other commonly used ICS, includ-
ing fluticasone propionate, mometasone fu-
roate, budesonide and ciclesonide. Fluticasone
furoate also has the largest cellular accumula-
tion and slowest rate of efflux among these ICS,
leading to prolonged efficacy and the potential
for once-daily dosing. [Am J Physiol Lung Cell
Mol Physiol 2007;293:L660L667]
Vilanterol is a long-acting beta2-adrenergic
agonist (LABA) that stimulates intracellular ad-
enyl cyclase to increase levels of cyclic-3,5-
adenosine monophosphate (cAMP). Increased
cAMP levels lead to relaxation of bronchial
smooth muscle and inhibition of release of
mediators of hypersensitivity. [Breo Ellipta Pre-
scribing Information]
Clinical efficacy
Two clinical trials of 1 year in duration have
demonstrated the effectiveness of fluticasone
furoate / vilanterol compared with vilanterol
alone. The studies enrolled patients aged 40
years and over, with a history of COPD and
smoking (10 pack-years) and history of one or
more moderate-to-severe exacerbations in the
In high-income countries, smoking
is the predominant cause whereas
in low-income countries indoor air
pollution associated with the use
of fuels for cooking and heating
produces most COPD burden
8/10/2019 Medical Tribune December 2014 REG
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DECEMBER 2014 DRUG PROFILE 15
previous year (approximately 1,300 patients in
each study). Subjects were randomized to ei-
ther 25 g vilanterol alone or 25 g vilanterol
combined with either 50 g, 100 g or 200 g
fluticasone furoate once daily. Combination
therapy provided a significant reduction in the
primary endpoint of annual rate of moderate-
to-severe COPD exacerbations. [Lancet Respir
Med2013;1:210-223]
Two other trials have examined the effect of
fluticasone furoate / vilanterol on lung function
compared with placebo and each component
alone. Both of these were 24 weeks in duration
and enrolled patients with stable moderate-to-
severe COPD. Acute (04 hours post-dose) and
trough (2324 hours post-dose) effects on lung
function were assessed. All active treatments
improved FEV, and confirmed that fluticasone fu-
roate / vilanterol results in significant, sustained
bronchodilation. [Respir Med 2013;107:550-
559, Respir Med2013;107:560-569]
Adverse effects
The treatment of patients with stable COPD
with fluticasone furoate / vilanterol in combina-
tion is usually well tolerated. Common side ef-
fects (occurring in 5 to 10 percent of patients)
include nasopharyngitis, upper respiratory tract
infection, headache, dysphonia and oropha-
ryngeal candidiasis. In the long-term clinical tri-
als of fluticasone furoate / vilanterol, fractures
and pneumonia were more common with the
combination therapy. Although the overall rate
of pneumonia was low, there were eight deaths
due to pneumonia in the fluticasone furoate /
vilanterol group and none with monotherapy.
As with other inhaled LABAs, vilanterol is as-
sociated with clinically significant cardiovascu-
lar 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
heart failure. In healthy subjects however, the
safety of single and repeat doses has been
demonstrated, with no deleterious effects upon
ECG measurement, QT interval or blood glu-
cose or potassium. [Int J COPD2014;9:249-56]
Dose and administration
Fluticasone furoate combined with vilanterol
is the first once-daily ICS/LABA combination to
be available (marketed under the trade names
Relvarand Breo). It is available in a new dry
powder inhaler delivery device (Ellipta) which
is designed for simplified usage. The dose for
maintenance therapy of COPD is one inhala-
tion daily, which delivers 100 g of fluticasone
furoate and 25 g of vilanterol. [Breo Ellipta
Prescribing Information]
Fluticasone furoate combined
with vilanterol is the first once-
daily ICS/LABA combination to
be available
8/10/2019 Medical Tribune December 2014 REG
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Essential Clinical
Practice Tool
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DECEMBER 2014 FEATURE 17
Preeclampsia is a hypertensive complica-tion of pregnancy, characterized by highblood pressure as well as possible kidney
damage. Typically, preeclampsia occurs after
20 weeks of pregnancy and, if untreated, can
pose significant threats to the mother and the
baby, especially if birth is premature. While the
symptoms of preeclampsia go away following
birth or more specifically, removal of the pla-
centa the condition leaves mothers with long-
term health risks.
The incidence rate of preeclampsia in devel-
oped nations is between 2 to 5 percent, higher
in developing countries. While the overall inci-
dence of preeclampsia is not high, the conse-
quences are severe. In Europe, for example,
the incidence of preeclampsia is about 3 per-
cent, but 25 percent of perinatal mortality is
caused by preeclampsia.
Importantly, preeclampsia is unpredictable.
Emerging trends in preeclampsia
Professor Holger Stepan
Director of ObstetricsUniversity Hospital LeipzigLeipzig, Germany
Preeclampsia is unpredictable. The cause of disease, aggressiveness, and speed of escalation varies from patient topatient.
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DECEMBER 2014 FEATURE 18
The cause of disease, aggressiveness, and
speed of escalation varies from patient to pa-
tient. For example, a pregnant woman in week
24 could be feeling fine but wakes up one
morning with some abdominal pain and if there
are complications, her situation can shift to very
severe within a day.
Predicting preeclampsia
The many other symptoms of preeclampsia
can be equally non-specific: excess protein in
the urine, headaches, blurred vision, nausea,
low platelet levels, shortness of breath, swell-
ing.
Other cases of preeclampsia may be less
severe. The problem is that a doctor with nor-
mal measures to assess pregnancy cannot dif-
ferentiate between normal, moderate, and high
danger. Those at risk include very young preg-
nant women (teenaged) or mature mothers
(over 40 years), twin pregnancies, overweight
women, women with kidney disease, and preg-
nant women with poor placental perfusion.
Early diagnosis is challenging, and in the
past doctors were only able to identify pre-
eclampsia as it occurred. However, the last de-
cade has seen the discovery of novel biomark-
ers that show promise both for early detection,
risk stratification and management.
A significant breakthrough in understand-
ing preeclampsia came about in 2002, when
Dr. Ananth Karumanchi, a kidney specialist at
Harvard University in Boston, Massachusetts,
US, observed the role of two proteins prior to
the onset of preeclampsia. During pregnancy,
the placenta releases placental growth factor
(PIGF), an angiogenic factor from the VEGF
family (a large group of proteins responsible for
blood vessel growth). Soluble fms-like tyrosine
kinase-1 (sFlt-1) is an antagonist to PIGF, bind-
ing to it and inhibiting cell growth.
In a normal pregnancy, these two proteins
are in balance ensuring the health of mother
and baby. Karumanchi showed that pregnant
women with preeclampsia have too much sFlt-
1 circulating in their blood, and too little PIGF.
This fundamentally changed the view of pre-
eclampsia and confirmed it as a state of imbal-
ance between angiogenic and anti-angiogenic
factors.
In addition to blood pressure monitoring or
proteinurea measures, blood tests for these
biomarkers have the potential to identify wom-
en at high risk of preeclampsia earlier in the
pregnancy, before the onset of the disease.
These types of biomarker tests are also
helpful for differential diagnosis. Typically, one
out of five women presenting with preeclamptic
symptoms will go on to develop preeclampsia.
If you can tell four of those women that they
will not develop preeclampsia, the benefit is tre-
mendous.
The emerging importance of a
biomarker ratio
A number of studies have shown that the ra-
tio of sFlt-1 to PlGF is more useful than either
measure alone. The ratio has proven highly
useful in helping clinicians identify which preg-
nant women are at highest risk and need to be
referred for timely interventions.
A European study of women with differing hy-
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DECEMBER 2014 FEATURE 19
pertension-related conditions and normal con-
trols (n=630) has shown that the sFlt-1/PIGF
ratio could be used to differentiate the various
types of hypertensive diseases in pregnancy.
The value was also found to correlate with the
time span from diagnosis until delivery; women
with the highest ratios had the shortest time
interval from diagnosis until delivery with the
most aggressive disease course while women
with the lower ratios had a longer time interval
and less aggressive disease.
At the moment, the only cure for preeclamp-
sia is removing the placenta. Simply lowering
blood pressure with antihypertensive medica-
tions will not stop preeclampsia because it is
driven by placental proteins. The disease seems
to originate from the placenta, if the placenta is
not removed during delivery, preeclampsia will
continue. And it is impossible to remove the pla-
centa without delivering the baby.
A specialized center with pediatricians expe-
rienced in premature babies is critical for pre-
eclamptic women. The goal of management is
to monitor maternal and fetal heart rate, well
being, ultrasound, and so on to pinpoint the
correct time for delivery too early and there
is risk for the baby, too late and there can be
complications for both mother and baby.
These placental proteins driving preeclamp-
sia are future targets for therapies but for now,
tracking their concentration can help indicate
when a woman can safely deliver.
New therapeutic approaches
for preeclampsia
Given the new understanding of preeclamp-
sia as a state of angiogenic imbalance, treat-
ments aimed at interfering with the effects of
sFlt-1 to restore the balance have shown initial
promise.
Extracorporeal removal of sFlt-1 from the
blood of a pregnant woman has shown favor-
able initial results. The future is in determining
whether the technique prolongs pregnancy
and improves maternal and fetal outcomes in a
larger patient population.
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DECEMBER 2014 FEATURE 20
Informed consent
Dr. Eugene WongConsultant Orthopedic and SpineSurgeonAdjunct Assistant ProfessorPerdana University Graduate School of
MedicineSerdang, Selangor
Patients should be educated prior to entry into clinical trials so they may give informed consent.
Informed consent is defined as approval orpermission given by the patient based onknowledge of the procedure or treatment to be
performed. The information includes the risks
and benefits, as well as alternatives to the pro-
posed treatment.
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 with-
out consent is an assault.
Informed consent differs from implied con-
sent. Consent is implied for gathering informa-
tion by history taking and performing neces-
sary examinations. Subsequent treatment plans
need to be discussed with the patient and in-
formed consent taken.
There are two types of consent. The first is
8/10/2019 Medical Tribune December 2014 REG
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DECEMBER 2014 FEATURE 21
the expressed consent, either oral or written,
given by the patient to undergo a specific pro-
cedure or treatment. Implied consent is inferred
from circumstances. It is rarely documented and
is relied upon for care or treatment that is rou-
tine and does not involve significant risks to the
patient. The doctor performing the procedure
or administering the treatment in question is re-
sponsible for engaging the patient in the con-
sent process.
Competence requires patients ability to un-
derstand the consequences of their decision and
the need of freedom from coercion. It requires
the ability to understand the proposed treatment
and make an informed decision. Competence is
usually assumed unless there are indications to
the contrary. Only an autonomous person can
give informed consent. If the patient is incom-
petent, proxy consent is allowed, but no more
than minimal risk to the patients is allowed. The
reasonable person and best interest judgment
standards need to be applied. A risk, even if it
is a mere possibility, should be regarded as sig-
nificant if its occurrence can cause serious con-
sequences.
Adequate decision-making capacity is the
ability to understand, evaluate and communicate.
As a rule, consent should not be obtained from
a sedated or anesthetized patient for an elective
procedure. Emergency treatment without con-
Competence
Adequate Disclosure
Adequate Understanding / Comprehension
Voluntary Decision
Consent
Table 1: Requirements for informed consent.Respects autonomy
Respects the right to control what happens to onesbody
Respects the right to control access to the self
Promotes greater social goods
Promotes trust between doctor and patient
Reduces liability and malpractice claims
Can be justified at least on utilitarian, deontological,and rights grounds, also on virtue ethics grounds.
Table 3: Justification for informed consent.
Difference in the knowledge base of the doctor andpatient
Patients are compromised by illness, anxiety, etc
Language of probabilities is unfamiliar to lay-persons
Takes too much time
Some patients just dont want to know
Table 4: Obstacles to informed consent.Nature of the procedure (diagnostic or therapeutic)
Probable complications
Risks involved, especially if they are severe andlikely to occur v
Expected benefits of the procedure
Alternatives to the procedure, along with their risksand benefits
Probable outcomes
Table 2: Features of adequate disclosure.
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DECEMBER 2014 FEATURE 22
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 self-
awareness- 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
Table 6: Informed consent Research on human subjects.
Risks/Benefits
Alternatives
Second opinion
Competence of doctor, team, institution
Nature of procedure
Life after recuperation, bodily and psychologicalchanges
Cost
Who is involved in the treatment?
Patients role in procedure, recovery
Conflicts of interest
Table 5: Informed consent for treatment.
sent may be undertaken if the patient is in im-
mediate need of treatment. The patient is unable
to provide consent because of physical or mental
impairment or because the patient is a minor. Im-
plied consent is required in cases of emergency
treatment, where it is presumed that the patient
would have consented to treatment if it is neces-
sary to save his life or from serious harm.
Research involving clinical trials of drugs or
treatments and research into the causes of, or
possible treatment for, a particular condition, is
important in increasing doctors ability to provide
effective care for present and future patients.
The benefits of the research may, however, be
uncertain and may not be experienced by the
person participating in the research. It is particu-
larly important that you ensure that the research
is not contrary to the individuals interests, the
participants understand that it is research and
that the results are not predictable.
Giving treatment without consent is a failure to
respect the patients autonomy and violates an
individuals right of self-determination. The con-
sent form is for patients to acknowledge that the
nature and purpose of treatment has been fully
explained, understood and consented to. Poor
handling of informed consent can lead to com-
plaints, medico-legal litigation and discipline for
negligence.
8/10/2019 Medical Tribune December 2014 REG
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DECEMBER 2014 CONFERENCE COVERAGE 24
CHUAH SU PING
There was a strong emphasis on the roleof tobacco smoking in the developmentof lung cancer at this years Asia Pacific Lung
Cancer Conference (APLCC) in Kuala Lumpur,
Malaysia. However, discussion regarding anoth-
er key risk factor outdoor air pollution was
strangely absent from the agenda.
The ASEAN region has 10 percent of the
worlds smokers, with Indonesia making up 51
percent of the distribution in the region, followed
by the Philippines with 13.6 percent and Viet-
nam with 12 percent, said Dr. Tara Singh Bam,
who represents the International Union Against
Tuberculosis and Lung Disease (The Union) in
Indonesia. He noted that here are approximately
127 million adult smokers in the ASEAN alone.
Smoking is the leading preventable cause
of death in the developed world and quickly be-
coming so in developing countries. Currently,
there are between 5 and 6 million deaths year-
ly in the world, and this figure is expected to
climb to 10 million by around 2025, said Dr.
Carolyn Dresler, associate director for Medical
and Health Sciences in the Office of Science
at the FDA Center for Tobacco Products Office,
US. If a smoker does not quit, then they have
a 50 percent chance of dying from a tobacco-
related disease.
In the Resolution presented at the close of
the conference, the first statement highlights
that Tobacco is a key risk factor for lung can-
cer claiming about 1.6 million lives globally ev-
ery year. The Resolution notes that complete
implementation of the WHO Framework Con-
vention on Tobacco Control (WHO FCTC) is
the most effective way forward for prevention
of lung cancer, and the APLCC supports full
implementation of the WHO FCTC especially in
all countries that are party to this treaty. Addi-
tionally, the Resolution noted, Tobacco prod-
ucts should be explicitly excluded from future
international, regional and bilateral trade and
investment agreements.
Air pollution a leading environmental cause
of cancer deaths (WHO, 2013)
In October 2013, the specialized cancer
agency of the WHO, the International Agency
for Research on Cancer (IARC), announced that
it had classified outdoor air pollution as carci-
Asia Pacific Lung CancerConference targets tobacco,
overlooks air pollution
2014 IASLC Asia Pacific Lung Cancer Conference, November 6-8,
Kuala Lumpur, Malaysia
8/10/2019 Medical Tribune December 2014 REG
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DECEMBER 2014 CONFERENCE COVERAGE 25
nogenic to humans (Group 1). This conclusion
was reached by leading experts convened by
the IARC Monographs Programme who, after
thorough review of the latest scientific literature,
concluded that there is sufficient evidence
that exposure to outdoor air pollution causes
lung cancer. [Press release no. 221, 17 October
2013, WHO]
Ambient air pollution (AAP) should also not
be ignored as a major cause of mortality, says
the WHO. In 2012 alone, 3.7 million deaths
globally were attributable to AAP, with about 88
percent of these deaths occurring in low- and
middle-income countries, which represent 82
percent of the world population. [Available at
www.who.int/phe/health_topics/outdoorair/da-
tabases/AAP_BoD_results_March2014.pdf. Ac-
cessed on 12 December 2014]
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DECEMBER 2014 CONFERENCE COVERAGE 26
KATHLIN AMBROSE
Hypoadiponectenemia in obese individualsplays a pathogenic role in the develop-ment of type 2 diabetes mellitus (T2DM) as well
as its complications, which include coronary ar-
tery disease, ischemic stroke and nephropathy.
Hence, the potential clinical applications of adi-
ponectin as a biomarker for predicting the de-
velopment of T2DM and its cardiovascular com-
plications, plus the development of therapeutic
targets, have been suggested based on cumu-
lative data from multiple studies. These studies
were described extensively by Professor Karen
Siu Ling Lam of the Li Ka Shing Faculty of Medi-
cine, University of Hong Kong.
In a meta-analysis of 13 prospective studies,
which included almost 15,000 subjects, high ad-
iponectin levels were observed to confer a lower
risk of T2DM relative risk of 0.72 per 1-log g/
mL increment in adiponectin levels. This inverse
association was consistently observed across all
populations, said Lam. [JAMA2009; 302:179-
188] In addition, Lam and her colleagues study
of non-diabetics in the Hong Kong Cardiovas-
cular Risk Factor Prevalence Study (CRISPS)
cohort showed that the combined use of serum
adiponectin and tumor necrosis factor-alpha
receptor 2 (TNF- R2) as biomarkers provid-
ed added-value over traditional risk factors for
T2DM prediction. [PloS one2012;7:e36868]
The association between adiponectin and
insulin sensitivity has also been analyzed at
the genetic level, where evidence of a causal
relationship was found in a study of Swedish
men. [Diabetes 2013; 62:1338-1344] This cor-
Making a case for adiponectin
in diabetes and its complications
Diabetes Asia 2014 Conference, October 16-19, Kuala Lumpur, Malaysia
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.
8/10/2019 Medical Tribune December 2014 REG
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DECEMBER 2014 CONFERENCE COVERAGE 27
responds to an earlier study in the CRISPS
cohort and a subsequent meta-analysis includ-
ing two European studies, which concluded
that the ADIPOQ single nucleotide polymor-
phism (SNP) T45G (rs2241766) independently
predicted persistent hyperglycemia at 5 years
and the development of T2DM. [Diabetologia
2006;49:1806-1815]
The link between adiponectin and T2DM is
taken further with associations found between
the protein and T2DM complications. A study
of a large Caucasian cohort showed that a vari-
ant of the ADIPOQ gene, adipo4 (rs266729),
which results in low adiponectin levels, is as-
sociated with increased carotid intima-media
thickness (CIMT), a marker of atherosclerosis
and a stroke risk factor, suggesting a causal
role of adiponectin in carotid atherosclerosis.
[Stroke 2011;42:1510-1514] This relationship
was also observed in a multi-ethnic population
and was even more marked in those with T2DM.
[Stroke2012;43:1123-1125] Hui et al confirmed
this relationship in a prospective study in the
CRISPS cohort, whereby low serum adiponec-
tin independently predicted progression of ca-
rotid atherosclerosis identified via CIMT incre-
ments over the years. [Metab Syndr Relat Disord
2014 Epub ahead of print] All these suggest that
adiponectin participates in the development of
carotid atherosclerosis. However, this was not
the case in ischemic stroke patients, although
serum adiponectin was indeed lower compared
to controls. A meta-analysis of eight prospec-
tive studies showed that in the long term, serum
adiponectin levels did not predict incidence, but
instead was found to be a good predictor of the
5-year survival rate following the first episode of
ischemic stroke. [Stroke 2014;45:10-17; Stroke
2005;36:1915-1919]
In almost all populations studied, there was
a clear indication that a high level of adiponectin
is protective against incident myocardial infarc-
tion (MI), even after correcting for cholesterol
levels. This produced up to a 40 percent MI risk
reduction in the Healthcare Professionals Fol-
low-up Study, said Lam. In obese individuals
who did not undergo bariatric surgery, a follow-
up of 10 years found that a protective effect for
the development of T2DM and MI was conferred
by adiponectin. This was confirmed by a 16-year
longitudinal study in the CRISPS cohort in which
the ADIPOQ gene +276G>T (rs1501299) SNP
when present even in the heterozygous state,
was associated with an increased risk of coro-
nary heart disease in men even after correcting
for confounding risk factors, she added.
In diabetic nephropathy, serum adiponectin
is inversely related to albumin excretion rates
in individuals with normal albuminuria. How-
ever, once the state of microalbuminuria or al-
buminuria is reached, the direction of the rela-
tionship is changed, with a positive correlation
observed between serum adiponectin and uri-
nary albumin concentration (UAC). An inverse
The myriad of studies described
show clear potential for themanipulation of adiponectin
in diseased states to create
therapeutic remedies
8/10/2019 Medical Tribune December 2014 REG
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DECEMBER 2014 CONFERENCE COVERAGE 28
relationship is also observed between serum
adiponectin levels and glomerular filtration rate
(GFR). However, patients with end-stage renal
failure have serum adiponectin levels as high
as controls, potentially as a result of a second-
ary phenomenon. [Kidney Int 2013;83:487-494;
Nephrol Dial Transplant 2014;doi:10.1093/ndt/
gfu249] These indicate that levels of serum adi-
ponectin differ according to phases of nephrop-
athy. In a prospective study of a small cohort
with relatively well preserved kidney function
followed up to 20 months, a low serum adipo-
nectin level was able to predict progression of
albuminuria, suggesting that in this selected
population, adiponectin is indeed protective
against renal failure, said Lam.
Fatty liver disease is another complication fre-
quently seen among T2DM patients. An inverse
relationship is seen between serum adiponec-
tin and serum alanine aminotransferase (ALT),
suggesting a protective effect conferred by the
protein. The increase in serum adiponectin lev-
els also correlates to improvements in hepatic
incidences. [J Clin Invest2003;112:91-100]
It is now commonly known that T2DM in-
creases the risk for the development of certain
types of cancers. These include cancer of the
pancreas, liver, colorectum, bladder and repro-
ductive tract. Adiponectin, working through vari-
ous signaling mechanisms, has been shown to
decrease cell proliferation in many animal- and
cell-based studies. In humans, low adiponectin
levels found in diabetes-related cancer patients
have been found to have a decreased ability to
limit proliferation and metastasis. [Endocr Relat
Cancer 2009;16:1103-1123; Diabetes Care
2010;33:1674-1685]
The myriad of studies described show clear
potential for the manipulation of adiponectin in
diseased states to create therapeutic remedies.
Current anti-diabetic and cardiovascular drugs
such as agonists of peroxisome proliferator-
activated receptor (PPAR) and statins are as-
sociated with increased plasma adiponectin in
humans. The recently discovered fibroblast
growth factor 21 (FGF21), a metabolic regula-
tor, is the most potent adiponectin stimulator to
date, said Lam. Many pharmaceutical com-
panies are now developing FGF21 mimetics
or analogues to improve the activity as well as
the circulating half-life of FGF21. All these are in
various stages of clinical trials, one of which has
already been used in a phase II clinical trial in
humans, she added.
Lam also briefly spoke of the importance
of lifestyle measures in improving adiponectin
levels, stating that a low-energy Mediterranean
diet, combined with increased physical activ-
ity, has shown to increase adiponectin levels by
30 percent over 2 years in individuals who suc-
ceeded in losing weight. [JAMA2003; 289:1799-
1804]
8/10/2019 Medical Tribune December 2014 REG
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DECEMBER 2014 CONFERENCE COVERAGE 29
DR. JOSLYN NGU
Metformin is commonly used to treat type 2diabetes mellitus (T2DM), but it may haveother benefits, says a prominent specialist.
In recent years, metformin has been suggest-
ed to have beneficial effects in type 1 diabetes
mellitus (T1DM), heart failure (HF) and cancer,
said Professor Andrew Morris, vice principal,
data science, School of Molecular, Genetic and
Population Health Sciences, University of Edin-
burgh, UK.
A systemic review of 197 clinical trials showed
that prescribing metformin on top of insulin ther-
apy to patients with T1DM reduces insulin-dose
requirement. Metformin was also linked to reduc-
tions in HbA1c, weight and total cholesterol. Still,
it is not conclusive whether these benefits last
more than a year and if there is any additional car-
dioprotective benefit. [Diabetologia2010;53:809-
820]
Currently, there are 24 clinical trials investigat-
ing the effects of metformin on HF, said Morris.
Examples of older studies that have demonstrat-
ed the cardioprotective benefit of metformin are,
for one, a Canadian study that ran from 1991 to
1996. The study analyzed the data of patients re-
ceiving oral anti-diabetic therapies from the Sas-
katchewan Health database. The researchers
found that metformin monotherapy or in com-
bination with sulfonylurea were associated with
improved mortality rates in patients with diabetes
and HF compared with sulfonylurea monothera-
py alone. [Diabetes Care 2005;28:2345-2351]
Another study alluding to metformins cardio-
protective benefit utilized information from the
Diabetes Audit and Research in Tayside Scot-
land (DARTS) database. The study included
diabetic patients who had a history of conges-
tive heart failure (CHF) and were prescribed oral
antidiabetic agents, but not insulin. The findings
concluded that metformin may lower the risk of
death in patients with CHF and DM when used
as monotherapy or in combination with sulfonyl-
urea. [Am J Cardio2010;106:1006-1010]
There is also the link between metformin and
cancer to be explored further. Metformin activates
AMP-activated protein kinase (AMPK) in hepato-
cytes, which leads to reduced hepatic glucose
production and increased glucose utilization. An-
drew said there is new insight into the function
of AMPK. As LKB1 is an upstream regulator of
AMPK and a known tumor suppressor, metformin
may be able to lower cell turnover and protein
synthesis. [J Biol2003;2:28] He said that based
on data from clinicaltrials.gov, there are currently
214 studies on metformin and cancer patients.
As Morris said, We are only at the beginning.
As the understanding of how metformin works
improves, so will the quality of treatment.
Diabetes Asia 2014 Conference, October 16-19, Kuala Lumpur, Malaysia
Possible future indications
for metformin
8/10/2019 Medical Tribune December 2014 REG
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DECEMBER 2014 CALENDAR 30
DECEMBER
20th World Congress onControversies in Obstetrics,Gynaecology and Infertility (COGI)
4/12/2014 to 7/12/2014Location: Paris, FranceInfo: COGI SecretariatTel: (972) 73 706 6950Fax: (972) 3 725 6266Email: [email protected]: www.congressmed.com/cogi
12th Asian Congress of Urology(ACU)
5/12/2014 to 9/12/2014Location: Kish Island, IranInfo: Secretariat
Tel: (971) 4 4218996Fax: (971) 4 4218838Email: [email protected]: http://12thacu2014.org
56th American Society ofHematology Annual Meeting andExposition (ASH)
6/12/2014 to 9/12/2014Location: San Francisco, USInfo: ASH Registration CenterTel: (1) 888-273-5704 - US andCanada
Tel: (1) 703-449-6418 - InternationalFax: (1) 703-563-2715Email: [email protected]: www.hematology.org
37th San Antonio Breast CancerSymposium (SABCS)
9/12/2014 to 13/12/2014Location: San Antonio, Texas, USInfo: SABCS RegistrationTel: (1) 210-450-1550Fax: (1) 210-450-1560Email: [email protected]
Website: www.sabcs.org
UPCOMING
International Conference onInfectious and Tropical Diseases
16/1/2015 to 18/1/2015
Phnom Penh, CambodiaInfo: Govt. Gandhi Memorial ScienceCollegeEmail: [email protected]: http://10times.com/ictid
9th Asia Pacific Conference onClinical Nutrition (APCCN)
26/1/2015 to 29/1/2015Location: Kuala Lumpur, MalaysiaInfo: Congress SecretariatTel: (603) 2162 0566Fax: (603) 2161 6560
Email: [email protected]: www.apccn2015.org.my
14th World Congress on PublicHealth
11/2/2015 to 15/2/2015Kolkata, IndiaPhone: (91) 124 463 6713Email: [email protected]: www.14wcph.org
24th Conference of the AsianPacific Association for the Study of
the Liver (APASL)12/3/2015 to 15/3/2015Location: Istanbul, TurkeyInfo: APASL SecretariatTel: (90) 312 440 50 11Fax: (90) 312 441 45 63Email: [email protected]: www.apasl2015.org
World Congress of Nephrology(WCN) 2015
13/3/2015 to 17/3/2015Location: Cape Town, South
AfricaInfo: International Society ofNephrologyTel: (32) 2 808 71 81Fax: (32) 2 808 4454Email: [email protected]: www.wcn2015.org
64th Annual Scientific Session ofthe American College of Cardiology(ACC)
14/3/2015 to 16/3/2015Location: San Diego, California, US
Info: ACC Registration and HousingCenterTel: (1) 703 449 6418Email: [email protected]: http://accscientificsession.cardiosource.org/ACC.aspx
6th Association of Southeast AsianPain Societies (ASEAPS) Congress
15/3/2015 to 17/3/2015Location: Manila, PhilippinesInfo: ASEAPS SecretariatTel: (65) 6292 0732
Fax: (65) 6292 4721Email: [email protected]: www.aseaps2015.org
16th World Congress on HumanReproduction
18/3/2015 to 21/3/2015Location: Berlin, GermanyInfo: Biomedical Technologies srlTel: (39) 070340293Fax: (39) 070307727Email: [email protected]: www.humanrep2015.com
4th Global Congress for Consensusin Pediatrics and Child Health (CIP)
19/3/2015 to 22/3/2015Location: Marrakech, MoroccoInfo: Paragon GroupTel: (41) 22 5330948Fax: (41) 22 5802953Email: [email protected]: http://2015.cipediatrics.org/marrakesh/
World Congress on Osteoporosis,
Osteoarthritis and MusculoskeletalDiseases (WCO-IOF)
26/3/2015 to 29/3/2015Location: Milan, ItalyInfo: Yolande Piette CommunicationTel: (32) 0 4 254 1225Fax: (32) 0 4 254 1290Email: [email protected]: www.wco-iof-esceo.org
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DECEMBER 2014 HUMOR 31
Forget about organic food.At your age, you need all the
preservatives you can get!
What do you meanyou feel dehydrated?
I had a great evening and Iwould love to ask you in, but I
heard you doctors dont makehouse calls!
Its about time you showed up!When did you discover thatyou were accident prone?
I dont think doctors are ready for,
what you call, post impressionism X-rays!
Shall we begin?
8/10/2019 Medical Tribune December 2014 REG
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For A 5-minute Update
Go towww.mims.asia/video
MIMS Video Series features
interviews with leading experts
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
_series Brought to you by MIMS
SCAN TO WATCH VIDEO
ProfessorPeter Ebeling
Widespread vitamin D
deficiency and low calcium
levels in Asians
How low levels of awareness
in the public and in
healthcare professionals
affect osteoporosis care in
Asia
Benefits of fracture
registries and fracture liaisonregistries (FLS) in Asia
ProfessorSerge Ferrari
Selective estrogen
receptor modulators
(SERMs), a new class of
therapy for post-menopausal
woman with osteoporosis
Dr Edith Lau
Treatment plans for
post-menopausal women
with osteoporosis
Professor BessDawson-Hughes
How aging contributes to
sarcopenia and impaired
muscle function in the
elderly
8/10/2019 Medical Tribune December 2014 REG
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P U B L I S H E R
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Christine Chok
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