Medical Tribune March 2012 MY2

8/2/2019 Medical Tribune March 2012 MY2

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www.medicaltribune.com

15-31 March 2012

Autumn in Kyoto

AFTER HOURS

Coronary calcium score

may help risk assessment in

asymptomac individuals

MALAYSIA FOCUS

Many women still shun contraceptives


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MTMAY15


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3 15-31 March 2012

Many women still shun contraceptives

Malvinderjit Kaur Dhillon

The Ministry of Health (MOH) is facinga setback in achieving the MillenniumDevelopment Goal (MDG) 5 as theMalaysian Populaon and Family Surveyshows a stagnant contracepve use prev-alence rate, says an expert.

The survey, carried out by the NaonalPopulaon and Family Development

Board at 10-year intervals beginning1974, showed the rate was 52 percent in1984 and almost stagnant at 51.9 percentin 2004. [Economic Planning Unit (EPU)Prime Ministers Department Malaysia.

www.epu.gov.my/c/document_library/

get_file?uuid=c1eb31df-0355-47c3-

9892-f57c795c504b&groupId=34492Accessed on 28 February]

According to the United NaonsDevelopment Programme [UNDP] goal,we have yet to achieve MDG 5 in termsof maternal mortality rao [MMR]and reproducve health services. Forexample, looking at MDG target 5a,we have to reduce the MMR by 75 per-cent by 2015. Currently, our MMR is28 per 100,000 births, and if we look

at the Ministry of Healths CondenalEnquiries into Maternal Deaths [CEMD],the rate is higher. Nevertheless, theMOH is condent it is on track andhopes to reach the target MMR of 11 per100,000 births, said Dato Aminah AbdulRahman, Director-General of the NaonalPopulaon and Family DevelopmentBoard (LPPKN). [UNDP. www.undp.org.

my/uploads/mdg5.pdf, EPU. www.epu.gov.my/c/document_ l ibrary/

get_file?uuid=c1eb31df-0355-47c3-

9892-f57c795c504b&groupId=34492

Accessed on 28 February]

There is also an unmet need for fam-ily planning. The rate of married womenwho do not plan on having any more chil-dren but are not using any form of contra-cepves is high. During the last decade,the unmet need has increased to 24.5percent from less than 20 percent previ-ously. Almost 27 percent of women donot pracse family planning as they are

afraid of the side eects. There is de-nitely room for educaon in this area.

A large number of women still do not practisebirth control due to various reasons.


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4 15-31 March 2012

Some 12.6 percent do not pracse fam-ily planning due to their husbands objec-on, said Aminah, who was speaking atthe launch of the Maternal and Infant Care

(Mi-CARE) program. [UNDP. www.undp.org.my/uploads/mdg5.pdf Accessed on28 February]

Aminah urged everyone involved in theMi-CARE program, as well as agencies pro-viding access to reproducve health, totake this as a challenge and to reach outto those who are marginalized or do nothave access to family planning services.

Mi-CARE was established by theObstetrics and Gynaecology Society ofMalaysia (OGSM), Nutrion Society ofMalaysia (NSM), the Naonal MidwivesSociety of Malaysia (NMSM) and theMalaysian Paediatric Associaon (MPA).

Mi-CARE aims to promote a more

holisc approach to pregnancy, birth andinfant care. The program involves train-ing workshops for midwives, nurses andnurse aides serving in maternity centers,

and private and government obstetricsand gynecology and pediatric clinics. Thecontent of the program was developedand will be delivered by a team of expertsin obstetrics and gynecology, diet andnutrion, physiotherapy and pediatrics.

Mi-CARE also aims to reach out to moth-ers via the Mi-CARE Telephone AdvisoryCentre*, which is manned by either a

nutrionist or a trained nurse.

Doctors wishing to enrol their nurses in the

Mi-CARE program can call the Secretariat at

(03) 5621 1408.

*Mi-CARE Telephone Advisory Centre: 1 800

88 9033


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5 15-31 March 2012 Forum

Turning the tide on chronic diseases in Asia:The need for innovative solutions

Excerpted from a presentation by Professor Harvey Fineberg, president ofthe Institute of Medicine and former Dean of the Harvard School of Pub-

lic Health, Cambridge, Massachusetts, US, during the National University

of Singapore Initiative to Improve Health in Asia (NIHA) forum held in

Singapore recently.

The two elements in the title, chronic

diseases and Asia, are each heteroge-neous and complicated.

The countries of Asia range from a

population of 400,000 in Brunei to morethan 1 billion each in India and China. Therange of economic development in theregion is equally disparate. The countriesalso vary in their stage of epidemiologictransition, with many simultaneously fac-

ing a high burden of infectious diseasesand chronic diseases. Although a singlesolution is unlikely to suit every countryin the region, certain lessons and princi-ples can apply across all.

The terminology of non-communi-

cable diseases is problematic. Manychronic diseases have infectious origins,including liver cancer (hepatitis B and

C), gastric cancer (H. pylori) cervical andoral cancers (human papillomavirus).Similarly, a number of acute illnesses arenot infectious.

The separation between acute andchronic, communicable and non-commu-nicable is, thus, imperfect. What unites

our concern about these diseases is thatthey persist over time, are prevalent in

all parts of the world, and are rising intheir incidence and significance as part

of the total disease burden.

Cancers, heart disease, lung disease,diabetes, and neurological and mentalproblems fall into this category. We tendto overlook this last group, but neurode-generave diseases and mental illnessessuch as depression will soon constute theleading cause of the global disease burden.

We need to apply our creative talentin new, innovative ways to come up with

novel solutions. One useful perspectiveis to consider diseases according to thestage of life and stage of disease evolu-tion in individuals and populations eg,problems of the young, the middle-agedand the elderly.

Another useful perspective is todesign interventions according to thestage of disease development, includ-

ing pre-disease, disposition to disease,early disease, full blown disease andsequelae of disease. The activities of theGlobal Taskforce on Expanded Access toCancer Care and Control in DevelopingCountries, which focus on low- and mid-dle-income countries and organizes itsthinking according to detection, diagno-sis, prevention, treatment, survivorship

and palliation of cancer, is a good exam-ple of this type of approach.


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8 15-31 March 2012 Medica l Br ie fs

Migraine in mother, colic in baby

Babies whose mothers have a historyof migraine are more likely to havecolic, a US study has shown.

The study, conducted by neurolo-gists at the University of California, SanFrancisco (UCSF), found that babieswhose mothers had a history of migrainewere two-and-a-half mes more likelyto have colic than infants whose moth-ers did not have a history of migraine.Overall, 29 percent of infants whose

mothers had migraine had colic com-pared to 11 percent of babies whosemothers did not have migraine.

For the study, researchers analyzedinformaon on 154 mothers and theirbabies. Colic was reported by parentsbased on quesons developed by studyresearchers using standard criteria forcolic.

The study ndings will be presented atthe American Academy of Neurologys 64th

Annual Meeng in New Orleans in April.Since migraine is a highly genetic

disorder, our study suggests that infantcolic may be an early sign that a childmay be predisposed toward migraineheadache later in life, said studyauthor Dr. Amy Gelfand, a child neurol-ogist with the Headache Center at theUCSF, and a member of the AmericanAcademy of Neurology.

Migraine ups depression risk in women

Migraine may lead to depression insome women, shows a US study.Women with a history of migraine were

found to be about 40 percent more likelyto develop depression than those with-out a history of migraine, according tothe study.

Researchers classied 36,154 womenwithout depression who were enrolled inthe Womens Health Study and had pro-vided informaon about migraine. Theywere classied as either having acve

migraine with or without aura, past his-tory of migraine (but not within the last

year) or no history of migraine.

A total of 6,456 women had current orpast migraine. During an average 14 years

of follow-up, 3,971 of the women devel-oped depression.The study ndings will be presented at

the American Academy of Neurologys 64thAnnual Meeng in New Orleans in April.

We hope our ndings will encouragedoctors to speak to their migraine paentsabout the risk of depression and poten-al ways to prevent depression, said Dr.

Tobias Kurth, of Brigham and WomensHospital in Boston.


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10 15-31 March 2012 Malaysia Focus

Coronary calcium score may help risk assessmentin asymptomatic individuals

Leonard Yap

Coronary calcium scores can be used inpredicng the risk of coronary arterydisease (CAD) in individuals with low-to-intermediate risk, says a cardiologist.

Coronary calcium scores are usually

considered to be the least accurate of non-invasive heart diagnosc tools, but they

sll have their place in cardiology, said Dr.Wong Teck Wee, a consultant cardiologist.This test is very easy, quick and very lowin radiaon [exposure].

The disadvantage of coronary calciumis that it does not look at stenosis, but ifyou have a calcium score of 0, the chanceof having signicant coronary stenosis isvery unlikely. The negave predicve value

is very high, 97 percent, and the higher thecalcium score, the more likely it is to havesignicant stenosis, he said. [ J Am CollCardiol2010;56:2182-99]

With this [informaon from the calciumscore] you can change the therapeuc goal[of your paent], you can get your paentto comply with lowering their cholesterol,

controlling blood pressure and keeping

their blood sugar under control.

Coronary calcium scores ulize com-puted tomography (CT) scan to check forthe build-up of calcium plaque on the wallsof the coronary arteries. This test is used

to check for heart disease at an early stageand to determine its severity. Coronary

calcium scores are also known as cardiaccalcium scans. In normal circumstances,coronary arteries do not contain calcium.Its presence is a sign of CAD. [www.nhlbi.nih.gov/health/health-topics/topics/

cscan/Accessed on 21 February]The American College of Cardiology

Foundaon/American Heart Associaon(ACCF/AHA) recommended coronary

artery calcium (CAC) scores in their 2010

ACCF/AHA Guideline for Assessment ofCardiovascular Risk in AsymptomacAdults for the following condions:

Measurement of CAC is reason-

able for cardiovascular risk assessment inasymptomac adults at intermediate risk

Calcium scores are a good indication of the stateof health of a patients coronary arteries.

... the higher the calcium score, the more likely it is to have

signicant stenosis


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11 15-31 March 2012 Malaysia Focus(10 percent to 20 percent 10-year risk).(Level of Evidence: B)

Measurement of CAC may be rea-sonable for cardiovascular risk assess-

ment in persons at low-to-intermediaterisk (6 percent to 10 percent 10-year risk).(Level of Evidence: B) [ J Am Coll Cardiol2010;56:2182-99]

There is evidence that CAC scores area reasonable surrogate for coronary ath-

erosclerosis burden in adults. [Circulaon

1995;15(92):2157-62, Am J Cardiol1994;73:1169-73]

A number of studies have demonstratedthe independent prognosc value of assess-

ing CAC to predict future coronary eventsin asymptomac individuals [Circulaon2000;101:850-5,Circulaon 1996;93:1951-3,J Am Coll Cardiol2000;36:1253-60]

Wong was speaking at the WeekendSeminar in Cardiology for GPs 2012 held inKuala Lumpur recently.

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Rotavirus: Vaccines the best preventive measure


Intervenonal measures, including improv-ing sanitaon and food hygiene, regulardisinfecon of hands and toys, and breast-feeding, alone are not enough in prevenngrotavirus infecon, says an expert.

The most eecve way to reduce severerotavirus-associated diarrhea and mortalityrates is through the use of the oral rotavirus

vaccine, said Dr. Chai Pei Fan, a consultantpediatrician, at a media brieng.

WHOs Strategic Advisory Group ofExperts (SAGE) emphasizes the use ofthe rotavirus vaccine as part of a disease-control strategy and has recommendedthat it be included in naonal immuni-zaon programs. (WHO. www.who.int/mediacentre/news/releases/2009/rota-

virus_vaccines_20090605/en/index.htmlAccessed on 24 February)

There are currently two vaccines avail-able in the market and the vaccine can beadministered as early as 6 weeks old. Thedoses should be completed between 6 and8 months, said Dr. Chai.

There is no specic anviral treatmentfor rotavirus. Most clinicians would proba-

bly prescribe the usual diarrhea medicaon,kaolin and pecn, which arent very eec-ve in children with gastroenteris. Morerecently, the use of diosmecte has becomemore common. It reduces the duraon ofdiarrhea, amount of stool and hospitaliza-on, but it will not stop a rotavirus infeconimmediately.

Chai stressed that the mainstay of treat-

ing paents infected with rotavirus is toprevent dehydraon, so oral rehydraon

therapy is highly recommended. However,

isotonic drinks do not provide adequateelectrolytes and are more suited for sports-men. In severe cases, especially in paentssuering from voming, rehydraon andmaintenance uid should be given intrave-nously. [Pediatr Infect Dis J 2003;52:1-16]

Children can be infected with the rota-virus several mes during their lives, andthe rst infecon is usually the worst.

[Australian Government Department ofHealth and Ageing. www.immunise.health.gov.au/internet/immunies/publishing.

nsf/Content/immunise-rotavirus Accessedon 24 February] Common symptoms of arotavirus infecon include severe diarrhea,frequent voming episodes lasng morethan 3 hours, a temperature of 39.4oC orhigher, and lethargy and irritability.

Ninety percent of infected paents areusually clinically dehydrated on admissionand 80 percent require IV uids. [Malaysian J Med2007;62:189-94] Severe dehydra-on may lead to death if le untreated.Therefore, it is important for clinicians to be

able to recognize symptoms of severe dehy-draon. (Table 1)

Table 1: Symptoms of a severelydehydrated child.

Weakness, redness or unconscious state.

Dry mouth and tongue.

No tears when crying.

Sunken eyes.

Reduced skin turgor.

Cold hands and feet.

Infrequent wet diapers.MWWR 2003;52(RR-16):1-16


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14 15-31 March 2012 Malaysia FocusSurveillance of visits to outpaent clin-

ics for acute gastroenteris (AGE) between1998 and 2000 showed a mortality rate of2.5 deaths per 100,000 children. [ J Infect

Dis 2005;192:S80-S86] Research conducted

at University Malaya Medical Centre overthe past 15 years and a 1-year naonwidesurvey found rotavirus to be the main causeof severe AGE in Malaysian children. [Med J

Malaysia 2007;62:189-193]

An easier method to measure protein intake

Leonard Yap

Figuring out whether your renal-impairedor malnourished paent is geng theright amount of protein in their diets canbe complicated and me consuming, saysan expert.

Convenonal methods to esmate apaents protein intake are too complexand me consuming to be used in clini-cal pracce, said Lim Su-Lin, senior assis-tant director and chief diean, dietecsdepartment, Naonal University Hospital,

Singapore. Thus, the need for a system toquickly esmate a paents protein intakeand make the necessary protein recom-mendaons in one sing, she said.

The expedited 10 g protein counter (EP-10) was developed to speed up the quan-caon of a paents dietary protein intakeand recommendaon for dietary adjust-ment in the clinical seng.

EP-10 dispenses with the need to useseparate protein calculaons for dierentfood groups to quanfy dietary proteinintake. This is done by making the followingassumpon: For every 10 g of protein con-sumed, 70 percent or 7 g of it is considereda high biological value protein (protein-rich). The remaining 3 g is considered tobe protein of low biological value. By mak-

ing this assumpon, foods high in starchescan be removed from consideraon. [J Ren

Nutr2012 Jan 6 Epub ahead of print]The EP-10 is a unied system that allows

easier quancaon of protein by ignoringnon-protein-rich foods and assigning EP-10

points to protein-rich food only. EP-10 isa relavely easy way to quanfy proteinintake and can be taught to doctors andpaents, Lim added. Paents, in parcular,will benet as they can esmate their ownprotein intake and make the necessary die-tary adjustments.

There has been no published literatureon a quick and suitable method of die-

tary protein intake esmaon for clinicalpracce. [Clin Nutr 2005:24:768-74, AmJ Clin Nutr1985:42;554-9] Currently, themost commonly used method is the 7 gProtein Exchange List developed by theAmerican Dietec Associaon in 1950for use in paents with diabetes mel-litus. [Diabetes Educ 1991;17:474-82, JAm Diet Assoc 2008;108:883-8] Lim was

speaking at a nutrion workshop held inKuala Lumpur recently.


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Extra-gastrointestinal manifestations of H. pylori


Helicobacter pylori has been linked toseveral condions and this has beenlabelled as the extra-gastrointesnal mani-festaon of the bacteria, but only two con-dions have the most convincing evidencethus far: idiopathic thrombocytopenia pur-pura (ITP) and unexplained iron deciencyanemia (IDA).

To prove a causal relaonship, rstlyyou really have to have a close relaonshipbetween the two. There has to be a biologi-

cally plausible mechanism, H. pylori infec-

on should precede the development of thedisease and, lastly, eradicaon of H. pylorishould result in an improvement in the con-dion or cure the disease, said Dr. Tan HuckJoo, a consultant gastroenterologist.

Several controlled prevalence stud-ies suggest a higher than expected prev-alence of H. pylori in paents with ITP.[Lancet1998;352(9131):878, Am J Hematol2000;65(4):329-30] Plausible mechanismsinclude molecular mimicry and cross reac-

vity of platelet and bacterial angens, inassociaon with host factors HLA class IIalleles. H. pylori induces anbody produc-on in response to angens that cross reactwith platelet glycoprotein. Eradicaon ofH. pylorihas been shown to result in clini-

cal benet to some paents and result inplatelet recovery, followed by disappear-ance of autoanbodies. [ Am J Hematol

2000;65(4):329-30]In summary, for ITP, there seems to be a

plausible mechanism between H. pyloriand

ITP. Eradicaon ofH. pyloriis useful in somepaents. The detecon and eradicaon ofH. pylori is worthwhile. There is obviouslya need for larger trials and longer term fol-low-up, said Tan.

A possible link between H. pyloriand IDAwas reported by several studies, with the rstcase report published in the early 1990s. [JPediatr Gastroenterol Nutr1993;17:225-7]

The suggested mechanism involves ironabsorpon interference due to an altera-on in duodenal mucosa as iron is mainlyabsorbed in the upper duodenum. Studiesshow that iron absorpon tests are normal-ized aer eradicaon ofH. pylori. [Dig LiverDis 2004;36(7):455-60]

The role of H. pylori in coronary artery

disease and stroke has also been studied.

In summary, in ischemic heart disease andH. pylori, the associaon seems to be weakand the epidemiological data conicng.Although there is a plausible mechanism,

it is not a great explanaon. There are nogood data to suggest that H. pylorieradica-

on is associated with low rates of ischemicheart disease, said Tan.

The role of H. pylori in Parkinson's dis-ease, Alzheimers and urcaria has alsobeen proposed. Although there are datasuggesng an associaon, the studies weremostly small and need to be conrmed witha larger study, he added.

Tan was speaking at the 2nd Asian

Pacific Meeting on Helicobacter Pylori inKuala Lumpur.

H. pyloriinfecon should precede the development of the disease


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17 15-31 March 2012 Regional

Survey reveals unmet needs in schizophreniamanagementChrisna Lau

Schizophrenia paents are more willingto be treated with long-acng inject-able atypical anpsychocs, but are fre-quently turned down by their physicianswhen requests for such medicaons aremade, according to a local survey.

The Hong Kong Familylink Mental Health

Advocacy Associaon interviewed 270schizophrenia paents and their familymembers in 2011 to invesgate paentsmedicaon use, knowledge of availablemedicaons and their healthcare needs.The mean age of the paents and caregiv-ers was 42 and 51, respecvely.

More than 90 percent of paents inthe survey were on oral anpsychocs.

However, 48 percent had disconnued oralmedicaons on their own.

While 33.9 percent of patients or fam-ily members had asked doctors for new-generation oral antipsychotics, such

requests were turned down 26.4 percentof the time.

Nearly half of the respondents believedthat new long-acng injecons are as

eecve as and more convenient thanoral anpsychocs. For these reasons,they indicated a higher willingness to betreated, reported Dr. Marcus Chiu, of thedepartment of social work, Hong KongBapst University, at a press conference.

Although 64.7 percent of the respond-ents had asked doctors for long-acnginjecons, such requests were turned

down 66.7 percent of the me.Schizophrenia paents oen

disconnue oral medicaons because offorgeulness, side eects and mispercep-ons that their condion has improved.While atypical oral anpsychocs are asso-ciated with fewer side eects, complianceremains a problem as long-term treatment

is required, said Dr. Sik-Chuen Ting, spe-

cialist in psychiatry.Long-acng injectable atypical anp-

sychocs can improve compliance and,therefore, reduce the risk of recurrence asthe injecons are administered by health-care professionals every 2 or 4 weeks.

However, these injecons are not com-monly used in clinical pracce because ofcost constraints. Furthermore, previous

research indicates that healthcare pro-fessionals oen believe injecons wouldcause pain and that paents would bereluctant to change treatment. Paentscompliance with oral anpsychocs hasalso been overesmated. [J Clin Psychiatry2004;65:120-31]

Use of long-acng injectable atypicalanpsychocs is associated with a health-

care cost saving of HKD 50 million peryear compared with oral medicaons,

Dr. Sik-Chuen Ting and Dr. Marcus Chiu.


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18 15-31 March 2012 Regionalsaid Chiu, who was referring to a retro-specve study conducted by the ChineseUniversity of Hong Kongs School ofPharmacy in 2003-2007.

The researchers thus suggested that

the Hospital Authority provide atypi-cal antipsychotics, such as long-acting

injections for schizophrenia patients, toreduce additional costs associated with

managing relapses.

Health education key to tackling chronic diseasesRajesh Kumar

Health educaon remains the key totackling a global epidemic of lifestylediseases including diabetes, heart diseaseand obesity, according to an expert.

Professor Gerard de Pouvourville, chairof health economics and management atthe ESSEC business school, Singapore, wasspeaking at the launch of the Europeanschools Instute of Health Economics andManagement for Asia Pacic.

We hear of a global epidemic of meta-bolic and cardiovascular diseases. But pub-lic health experts agree this could havebeen avoided through health educaonand early intervenon decades ago, beforeit reached the current stage. Now, we arewondering how to roll it back and how to

manage it eecvely, said Pouvourville.Giving the example of France, which

recently cut primary healthcare fundingfollowing concerns over excessive use ofGP services and medicines, Pouvourvillesaid those are precisely the type of errorswe need to avoid now if we really want toaddress prevenon.

But the new economic reality is that all

countries, rich or poor, need to improvethe management of their scarce healthcare

resources to tackle these challenges more

eecvely, he said.Market and industry research indicates a

growing demand for accessible, high-qual-

ity healthcare services and health insurancethroughout the Asia-Pacic region. And theinstutes research and training programscould help generate new ideas and innova-ons from the region itself, he said.

The new instute will be dedicated toresearch and development in health tech-nology assessment, strategic hospital man-

agement, healthcare services funding andorganizaon, health insurance economics,and the impact of health regulaons onbiomedical innovaon and market access.It has already garnered strong interest inthe region through educaon grants fromhealthcare companies including Johnson

& Johnson, Medtronic, sano, UCB andVifor Pharma.

Its inaugural program in health tech-nology assessment: denions, objecves,methodologies and contribuons to deci-sion making process aracted the regionskey healthcare policymakers, health insur-

ers and providers in-charge of designingand implemenng rules and regulaons

for the access to healthcare technologiesin their respecve countries.

... the instutes research and training programs could help generate

new ideas and innovaons from the region itself


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Coffee may reduce fibrosis risk in patients withNASH

Elvira Manzano

Increased intake of coee may hold thekey to decreasing the risk of advancedbrosis scarring in people with fayliver disease, research suggests.

In a study of 306 paents with nonal-coholic steatohepas (NASH), high con-sumpon of coee signicantly decreased

the formaon of excess brous connec-ve ssue in their liver. [Hepatology2012;55(2):429-36. doi: 10.1002/hep.24731]

Our study is the rst to demonstrate ahistopathologic correlaon between fayliver disease and esmated coee intake,said study author Dr. Stephen Harrison,lieutenant colonel in the US Army based atBrooke Army Medical Center in Fort Sam

Houston, Texas, US. Moderate coee con-sumpon may be a benign adjunct to thecomprehensive management of paentswith NASH.

Harrison and his team studied the cof-fee consumpon of parcipants from aprevious non-alcoholic fay liver disease(NAFLD) study and NASH paents treatedat the centers clinic and categorized them

into four groups paents with no sign ofbrosis (controls), steatosis, NASH stage0-1, and NASH stage 2-4.

There was a signicant dierence in thecaeine consumpon of paents with stea-tosis compared to paents with NASH stage0-1 (P=0.005). Addionally, coee consump-on was signicantly greater in paentswith NASH stage 0-1 than with NASH stage

2-4 (58 percent versus 36 percent of caf-feine intake from regular coee, P=0.016).

There was a stepwise decrease in cof-fee consumpon as brosis increase,Harrison explained. This would suggestthat other properes of coee beyondcaeine may aect disease progression inNASH paents.

Caeine intake has long been associatedwith a reduced risk of hepatocellular car-cinoma, and reduced brosis and cirrhosis

in paents with chronic liver diseases suchas hepas C. [Hepatology2009;50:1360;Hepatology2010;51:201]

It has also recently been suggested thatcoee may protect against diabetes andendometrial cancer.

Knowing the benecial eects of coeeintake on liver diseases, future prospec-ve research should examine the amount

of coee intake on clinical outcomes,Harrison concluded.

Commenng on the study, Dr. VincentWong, professor, department of medicineand therapeucs director, Center for LiverHealth, The Chinese University of Hong Kongsaid the current paper adds to the exisngliterature showing that the same phenom-

enon is observed in NAFLD paents.

The study has a relavely large samplesize. The exisng literature is rather con-sistent on the associaon between coeeintake and liver injury. However, limitedby the nature of observaonal studies,causal relaonship is dicult to estab-lish, he said. For example, instead ofdirect causal eect, coee intake may beassociated with less liver brosis through

dierences in smoking, alcohol use andphysical acvity.


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Non-drug approaches help alleviate cancer pain

Elvira Manzano

Non-pharmacological, psychosocialintervenons are a valid and eecveopon for the treatment of pain in paentswith cancer, according to a recently pub-lished meta-analysis.

Pain is one of the most common, bur-

densome and feared symptoms experi-enced by paents with cancer, said Dr.

Paul B. Jacobsen, lead study author andassociate director for Mots Division ofPopulaon Science, Tampa, Florida, US.The posive ndings from this meta-anal-ysis considerably advance support for theimportance of psychosocial intervenonsin reducing pain in cancer paents.

Jacobsen and colleagues analyzed 37randomized controlled studies of psy-

chosocial intervenons involving a totalof 4,199 adult paents with cancer. Thestudies were published between 1966and 2010. [J Clin Oncol2012. Jan 23. Epubahead of print]

Across the studies, psychosocial interven-ons were found to provide weighted aver-aged eect sizes of 0.34 (95% CI 0.23-0.46;P


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21 15-31 March 2012 Regionalmake the pain worse so they can feel they

are in control, Goh explained. But in somechronic pain situaons, paents needmore than explanaons given at a medi-

cal consultaon. Somemes, they need togo through certain kinds of training to helpthem think about their pain in a dierentway, or change their behavior which makesthe pain worse.

She said these kinds of training may bedone in a group, or individually. I have seenpaents who have undergone cognivebehavior therapy and beneted from it.

Other intervenons include more con-tact with a nurse or a therapist for follow-

up and educaon about their pain.Goh said the study has been carefully

done and the informaon it provides is val-uable and adds to exisng knowledge. Ithink it is important that any intervenonsbe properly evaluated through randomized

controlled trials, and meta-analyses of suchtrials. But it is parcularly important whenit comes to psychosocial intervenons, asthere is less standardizaon of such inter-venons, and many medical doctors, whoare more used to prescribing drugs ordoing operave procedures, are less con-vinced of their ecacy.

Up to one-third of cancer paents suf-

fer from moderate to severe pain whichinterferes with sleep, daily life acvi-es, enjoyment of life, work ability andsocial interacons.

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Further curbs on obstetric services fornon-locals in HK

Naomi Rodrig

Against growing public discontentdenouncing the increasing numberof mainland Chinese women giving birthin Hong Kong, the Hospital Authoity (HA)

recently reviewed and revised its regula-ons on obstetric service provision in 2013.

A review of the 2012 delivery bookings

by the HAs Taskforce on Obstetric Servicesfor Non-eligible Persons (NEP) showed thatthere is a higher demand from local expect-ant mothers than the original forecast, theHA spokesperson said.

As a result, Princess Margaret Hospital

has ceased to accept bookings from non-localmothers for the rest of 2012, while QueenMary Hospital will also reduce the obstetricquota for non-locals in coming months.

Last year, about 41,000 mainland NEP gavebirth in Hong Kong hospitals, accounng fornearly half of the total births in the city.

Given the burden on the obstetric andneonatal units with the surge in non-local

expectant mothers using public hospi-tal services, the government has limitedthe number of non-local births in the

city in 2012 to 34,000. While describedas a step in the right direcon, it doesnot address the plight of local pregnantwomen who oen are unable to reservehospital beds for delivery because of theinux of non-locals.

Having considered the service capaciesand priories for local expectant mothers in

2013 and the consequent demand for neo-natal services, the taskforce reiterated thepriority for local pregnant women in booking

of obstetric services, and proposed a prelimi-nary plan on quotas for non-locals in 2013.

The prime responsibility of our hospitals

is to ensure adequate and up-to-standardservices for local mothers as well as new-borns. We will closely monitor the service

booking situaon and adjust the servicequota to ensure local demand is alwaysmet, said Dr. Wai-Lun Cheung, HA Director(Cluster Services) who chaired the meeng.

The taskforce recommended that four

public hospitals (Kwong Wah, Princess

Margaret, Prince of Wales and Tuen Mun)not accept any bookings of non-local moth-

ers next year, while the quota of the remain-ing four hospitals (Pamela Youde NethersoleEastern, Queen Elizabeth, Queen Maryand United Chrisan) will be furtherreduced to below 3,000 in total.

The proposed plan will be submied tothe Food and Health Bureau for considera-

on against the supply and demand situa-on of obstetric services in both the publicand private sectors.

As complementary measures, the gov-ernment is ghtening up the borders andcracking down on so-called birth agentsshuling mainland women into the city togive birth.

In mid-February, a mainlander who

brought pregnant women into Hong Kongwas sentenced to 10 months in prison.

We will adjust the service quota to ensure local demand is always met


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MTFEB15-12/001


24/46


Removing the root of cancer

Chrisna Lau

Researchers in Hong Kong have devel-oped a novel class of compoundsthat can inhibit the growth of cancer

stem cells.

Cancer stem cells are a small group of

cells in tumors with the ability to prolif-

erate and self-renew, and to dieren-ate into heterogeneous cancer cells that

constute the enre tumor mass. Beingresistant to convenonal cancer therapy,they are very dicult to eradicate and arethe source of relapse and metastasis.

In a joint study by the Hong KongPolytechnic University (HKPU), PekingUniversity Shenzhen Graduate School,and Nevada Cancer Instute in Las Vegas,US, researchers have developed a novelclass of compounds that could inhibit thegrowth of cancer stem cells. [Cancer Res2011;71:7238-49]

The compounds were specic bioacvesmall inhibitors of lysine-specic dem-ethylase 1 (LSD1), a histone demethylasethat is highly expressed in many tumors.

These LSD1 inhibitors were found toinhibit the proliferaon of pluripotentcancer cells, including teratocarcinoma,embryonic carcinoma and seminoma orembryonic stem cells expressing the stem

cell markers Oct4 and Sox2.However, there was lile growth-inhib-

itory eect on non-pluripotent cancer

cells or normal somac cells.The potenal clinical applicaons

of LSD1 inhibitors include treatmentof malignant germ cell tumors, such as

teratomas or teratocarcinomas, embry-

onic carcinomas, seminomas, chorio-

carcinomas, and tumors of yolk sac,

which oen become resistant to inialplanum treatment, said Dr. Tao Ye, ofHKPUs department of applied biology andchemical technology who led the study.

The compounds can also be used toremove teratomas or embryonic carci-nomas during stem cell-based therapyand to inhibit organ-specic cancers with

stem cell-like cells, such as breast andovarian cancers.

The compounds can also be used to remove teratomas ...


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Even elderly smokers benefit from quitting

Radha Chitale

Long-term smokers who quit, even thoseover 60, experience signicant healthbenets within 5 years, according to aSingapore study.

Lead researcher Dr. Woon-Puay Koh, anepidemiologist at the Naonal University ofSingapore, said the purpose of the study wasto determine how rapidly those who quit

smoking were able to see substanal results.One of the most common reasons for not

quing smoking in an elderly person is: WellIve always smoked for so long, and Im alreadyat this age ... If I quit now, will I have any benetto quing compared to someone who has juststarted smoking and quit quickly? she said.

Using data from the Singapore ChineseHealth Study, a cohort of 52,322 adults aged

45 to 74 years were surveyed twice abouttheir medical history, smoking status andother lifestyle factors rst between 1993 and1998 and again between 1999 and 2004. [TobControl2011 Dec 14. Epub ahead of print]

According to data from the 2010 NaonalHealth Survey, 14.3 percent of Singaporeanmen and 4.2 percent of Singaporean womensmoke, and the current studys predomi-

nantly male subject group reected that.Parcipants were grouped into never

smokers (72.5 percent), long-term quit-ters (8.9 percent; quit before recruitment,mean 17 years), new quiers (3.6 percent,quit between recruitment and follow up,mean 4.3 years) and current smokers (15percent). Mean follow up was 8.1 years.

Aer adjusng for lifestyle, new quit-

ters and long-term quiers reduced theirrisk of death from lung cancer by 24 and

56 percent at follow up, respecvely, com-

pared with current smokers.Risk of total mortality fell by 16 and 29percent among new and long-term quit-ters, respecvely. The risk reducons heldtrue aer further adjustment in whichparcipants with chronic diseases wereexcluded from analysis (N=36,387).

Whats interesng is that in this groupof new quiers that we have studied, they

have smoked an average of 39 years, Kohsaid. So these are really long-term smok-ers who at the age of 60 decided to quit,and we do see benets.

Cessaon was also associated with anon-signicant reduced risk of coronaryheart disease and almost no dierence instroke-related mortality. Long-term quit-ters showed a 32 percent reduced rate of

COPD-related death, but this rate increasedamong new quiers by 23 percent.

The mechanics of lung repair comparedto circulatory replenishment may explain

the dierences in the short-term eectsof cessaon on lung disease versus heartdisease. Structural damage to the lungsmay take years to reverse, while the eectof smoking on circulaon may be relavely

faster to reverse, Koh said.In addion, new quiers are more likely

to stop smoking because they are experi-

encing health problems and so is a groupthat, as a whole, may be more sick than

long-term quiers or current smokers.Based on their results, Koh noted that

in addion to smoking prevenon, pub-lic health strategies targeng cessaon in

current smokers, even those over age 60,could yield health benets.


26/46MTMAR15-12/0


27/46


Pediatric EEG commonly misusedin Hong Kong

Naomi Rodrig

Alocal study has found that nearly halfof the referrals for standard electroen-cephalography (EEG) in pediatric pracceare inappropriate, prompng the authorsto call for more judicious use of the testbased on current guidelines. [Hong KongMed J 2012;18:25-9]

Invesgators from the departmentof pediatrics and the ElectrodiagnoscMedical Unit at Tuen Mun Hospital evalu-ated the records of 109 children who under-went standard EEG between December2009 and February 2010.

Overall, 44 percent of the EEG requestswere inappropriate with respect to guide-lines, of which 50 percent were for the diag-

nosis of funny turns, 23 percent for febrileconvulsions and 23 percent for monitoringpaents with established epilepsy.

According to the guidelines, standard EEGis not recommended in these condions as itis not helpful or even misleading. Conversely,EEG referrals are appropriate in case of de-nite or probable epilepc seizures and classi-caon of newly diagnosed epilepsy, as well

as in cases of encephalopathy, neuro-degen-eraon and organic brain disturbances.

Of the appropriate requests in the study,89 percent were correctly made to supporta diagnosis of epilepsy based on strongclinical suspicion.

Interesngly, both specialists and non-

specialists made inappropriate referrals for

EEG (45 and 40 percent, respecvely). The

authors suggest that unrestricted accessto standard EEG in Hong Kong hospitals

leads to unjused requests, in parcularfrom nonspecialists (86 percent of the 109

cases). There is considerable potenal for

unnecessary requests and misinterpreta-

on of the results, claimed WC Lee et al.

Importantly, the EEG results oen do notcontribute to clinical management. In thestudy, EEG results did not aect subsequentmanagement in all inappropriate referrals as

well as in 49 percent of appropriate refer-rals. Overall, the standard EEG contributedto the diagnosis or management in only 28percent of paents, they wrote.

These data conrm previous overseasreports that misconcepons about the diag-nosc capability of EEG are common, leadingto abuses. The authors believe that subop-mal use of the EEG service is typical of most

regional hospitals in Hong Kong and thestudy results can be generalized.

They specically warn of EEG misuse toexclude epilepsy, which is almost impos-sible, as the diagnosis of epilepsy is clinical.Moreover, so-called false-posive EEG nd-ings can be as high as 0.5 percent Thisincreases the risk of misdiagnosing epilepsyand its aendant important consequences,

including inappropriate drug treatment andthe psychological trauma of being labeledepilepc, they wrote.

Aribung the pediatric EEG abuse tomisconcepons regarding its role and limita-ons, the invesgators suggest that physicianeducaon may help. Through an educave,non-confrontaonal approach, and withme to explain guideline recommendaons

to clinicians, sustainable change in praccecould be achieved, they recommended.


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AF patients on warfarin warned aboutherbal foodstuffs

Christina Lau

Paents with atrial brillaon (AF)treated with warfarin should watch outfor a number of foods and herbs commonlyused in Chinese cooking, as frequent con-sumpon of these ingredients is associatedwith subopmal ancoagulaon control ina recent study.

Many AF patients know that warfa-rin interacts with green leafy vegetablesand beans, which contain large amountsof vitamin K. But few are aware thatfoods with herbal ingredients used inChinese cooking may augment or inhibit

its anticoagulation effect, said ProfessorHung-Fat Tse, of the division of cardiol-ogy, University of Hong Kong, who led

the study.The study included 250 paents with

nonvalvular AF who had been treated withwarfarin for at least 6 months. They wereasked about consumpon of foods withherbal ingredients that may interact withwarfarin in the past 12 months using astandardized quesonnaire.

The researchers then investigated

the effect of the concomitant consump-tion on INR (International NormalizedRatio) control. [J Cardiovasc Pharmacol2011;58:87-90]

Up to 50 percent of paents reportedconsumpon of foods with herbal ingredi-ents that may interact with warfarin. The

most commonly consumed foods weregarlic (80 percent), ginger (75 percent),

papaya (55 percent), green tea (50 per-cent), ginkgo (40 percent) and Chinese

wolerry (25 percent).Herbal drugs such as ginseng (4 percent),

danshen (1.2 percent) and dong guai (0.8percent) were uncommonly consumed.

Importantly, frequent users whoconsumed more than one kind of herbfor at least four times per week were

less likely to stay within the optimal

therapeutic INR range of 2-3 than infre-quent users who consumed one kindof herb for fewer than four times per

week, pointed out Tse. Frequent usershad their INR out of optimal therapeutic

range 49 percent of the time, comparedwith 42 percent of the time for infre-quent users.

This study highlights the issue of limitedknowledge in warfarin-treated AF paentsof the potenal interacon betweenherbal substances in foods and warfarin,he connued.

Although we did not measure the

amounts of foods with herbal ingre-dients consumed by the patients,

Table. Foods with herbal ingredients thatmay interact with wararin.

Increase INR/augment the eect o wararin: Chinesewolfberry()

Danshen()

Devilsclaw()

Dongquai()

Fenugreek()

Feverfew()

Garlic

Ginger

Ginkgo

Papaya

DecreaseINR/inhibitoryeectofwarfarin:

Ginseng Greentea

StJohnswort

Adapted fromJ Cardiovasc Pharmacol2011;58:87-90.


29/46

29 15-31 March 2012 Regionalover-consumption of such foods may affectINR control, increasing the risk of strokeor bleeding.

Tse suggested that warfarin-treated

paents should be educated on the foods

and ingredients that can potenally aectINR. Dietary restricons and regularmonitoring are important to make sure

that INR is maintained within the opmal

therapeuc range.

Cough medicine abuse linked to muscle damageNaomi Rodrig

Cough mixture overdose has beenassociated with severe folate defi-ciency, which may cause rhabdomy-olysis, as demonstrated in several casereports featured recently in the HongKong Medical Journal. [Hong Kong MedJ 2012;18:68-9]

According to study authors, from thedepartment of psychiatry at Kwai ChungHospital and the department of medi-cine at Queen Mary Hospital, cough

mixture abuse is an emerging problemamong young men, and its metabolicconsequences have been recognized onlyrecently. These include severe renal dam-age, metabolic acidosis, and severe folatedeciency that can lead to neurologicaland hematological eects. However, mus-culoskeletal side eects have not beenrecognized as yet.

They reported three cases of youngmen (age 29 to 32), who presented withconfusion, uncoordinated limb move-ments, rigid limb tone, myalgia and mus-cle weakness. All patients had a historyof antipsychotic drug abuse and coughmedication overdosing (30 cough tabletsor >2 bottles of cough syrup daily), andwere diagnosed with folate deficiency

(125, 63 and 61 g/mL versus referencelevel of >164 g/mL). An open muscle

biopsy in one of the patients showednecrotizing myopathy with degenerat-ing fibers and sarcoplasmic vacuolation,while a sural nerve biopsy showed severe

axonal degeneration.Rhabdomyolysis is an uncommon clini-

cal emergency related to illicit drug andalcohol abuse; it may result in renal shut-down, hyperkalemia, hyperphosphatemiaand death.

Aer excluding the inial dierenaldiagnoses, the authors concluded thatfolate deciency was implicated in the

muscle damage, although myoglobinu-ria was documented in only two of thepaents. Large doses of codeine as well aslow folate levels are known to have myo-pathic eects.

All these are suggesve of a causaveeect. Interacons with other components(eg, pseudoephedrine), impuries or addi-ves in the illicit cough mixture might also

aggravate the musculoskeletal damage,they wrote.

They pointed out that cough mixtureabuse is often perceived as relativelyharmless, but in fact may have dam-aging metabolic and neuropsychiatricsequela. Therefore, they suggest a highindex of suspicion, so clinicians can ini-tiate early investigation and treatment

to minimize any permanent muscle orkidney damage.


30/46

Further information is available upon request. * References on file.


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31 15-31 March 2012 Internat ional

Dual-arm BP difference may indicatevascular disease

Leonard Yap

Large dierences in blood pressure (BP)measurement between both arms mayprove to be a useful indicator of increasedrisk of vascular disease and even death,according to a UK study.

Researchers at the University of ExeterPeninsula College of Medicine and Denstry

(PCMD) found that dierences of 15 mmHgor more in systolic BP measurements

between arms indicated an increased riskof peripheral vascular disease (the nar-rowing and hardening of the arteries thatsupply blood to the legs and feet); cerebro-vascular disease (aecng the blood sup-ply to the brain and oen associated withcognive issues such as demena); and

mortality. The risk of peripheral vasculardisease was also increased at a dierenceof 10 mmHg or more.

The ndings were published in the Lancet

online and the study was supported by

the Royal College of General Praconers,

the South West GP Trust and the Naonal

Instute for Health Research Peninsula

Collaboraon for Leadership in Applied

Health Research and Care. [doi:10.1016/S0140-6736(11)61710-8]

A systemac review and meta-analy-sis by researchers at PCMD examined 28papers covering dierences in systolic BPreadings between arms.

We set out to invesgate whether therewas an associaon between dierences insystolic blood pressure between arms and

vascular disease and mortality. Our nd-ings indicate a strong associaon, and that

dierences of 10 mmHg or 15 mmHg or moremight help to idenfy paents who are at riskand who need further vascular assessment.

However, more research is requiredin order to transfer our ndings to clinicalpracce, but in the meanwhile we will beagging the results of our review to theUK Vascular Check programme, said Dr.Christopher Clark, clinical academic fellow

at PCMD and a GP in Witheridge, Devon,and lead author of the study.

In an accompanying comment, Dr. RichardMcManus, of University of Oxford, and Dr.Jonathan Mant, of University of Cambridge,said that the new ndings reinforce exisngguidance statements that recommend bloodpressure measurements be taken from both

arms and that this should become part of

roune care, as opposed to a guideline rec-ommendaon that is mostly ignored.

Dual-arm blood pressure may give doctors a betterindication of a patients cardiovascular health.


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Tai chi improves balance, reduces falls inParkinsons

Radha Chitale

Tai chi exercises proved beer at improv-ing balance and reducing the risk offalls among adults with Parkinsons diseasecompared with strength training or simplestretching, according to a study.

Physical acvity has been shown toretard the deterioraon of motor funcons

and to prolong funconal independence,the study authors said.

Paents with the neurodegeneravedisease are le with impaired balance, lessstability, gait dysfuncon, poorer quality oflife due to reduced funconal abilies andan increased risk of falls.

These symptoms are largely unaectedby drug therapy and exercise is recom-

mended. However, the researchers notethat resistance training, which has been

shown to address balance and strength def-icits, requires monitoring and equipment.

We hypothesized that tai chi would bemore eecve in improving postural stabil-ity in limits-of-stability tasks than a resist-

ance-based exercise regime or low impactstretching, they said.

A group of 195 paents with mild-to-moderate Parkinsons disease were ran-domly assigned to receive twice-weekly60-minute sessions of tai chi, resistancetraining or stretching (control) for 24weeks. [N Engl J Med2012;366:511-9]

The tai chi protocol was designed to taxbalance and gait by focusing on symmetricand diagonal movement, weight shiing,

controlled center of gravity displacement,ankle sways, and anterior-posterior and

lateral stepping.Resistance training focused on the mus-cles important for posture, balance andgait, including squats, lunges and heeland toe raises, using weighted vests andankle weights.

Seated and standing stretches for theupper body and legs provided a low inten-sity control group.

Tai chi paents performed beer thanthe resistance and stretching groups in theprimary outcome measures tesng thelimits-of-stability, which assesses how far

paents can lean in a number of direconswithout falling, and at direconal control,which measures movement accuracy.

There were 381 falls in 76 paentsoverall but the incidence rate was 67 per-

cent lower for the tai chi group comparedwith the stretching group (0.22 vs 0.33,P=0.005). Tai chi paents experiencedmarginally fewer falls than the resistance

training group, whose incidence rate was0.47, but this was not signicant (P=0.05).

Tai chi paents performed beer in allsecondary outcome measures comparedwith the stretching group, including gait,

knee movement, funconal reach, andme to stand from sing. They performedbeer than the resistance group at stridelength and funconal reach.

The eects were maintained 3 monthsaer compleng intervenon.

The trial did not measure the net gain oftai chi exercise but only as compared to lowintensity, low impact stretching regimes.

Clinically, these changes indi-cate increased potenal for eecvely


33/46


performing daily life funcons, such asreaching forward to take objects from acabinet, transioning from a seated to a

standing posion (and from standing toseated), and walking, while reducing theprobability of falls, the researchers said.

Daily milk boosts brain power

Elvira Manzano

Frequent intake of dairy food an importantstep to building strong bones and prevent-ing osteoporosis also enhances cognivefunconing, recent research has shown.

A cross-seconal meta-analysis of thedietary habits and mental funconing of972 adults in the US has found that indi-viduals who consumed dairy productsonce a day had signicantly higher scoresin memory and other cognive tests com-pared with those who never or rarely con-sumed dairy food. Individuals with highmilk consumpon were also ve mes less

likely to fail the tests compared with non-milk drinkers. [Internaonal Dairy Journal2011.DOI:10.1016/j.idairyj.2011.08.001]

While lile is known about the under-lying mechanisms of dairys benets oncognive funconing, the authors said itsunique nutrient content might play a role.

Dairy foods contain a number ofimportant nutrients such as calcium, whey

protein, vitamin D, magnesium and phos-phorus, said lead researcher Ms GeorginaCrichton, from the Nutrional PhysiologyResearch Centre, University of SouthAustralia, Adelaide, Australia.

Adult subjects aged 23 to 98 who wereincluded in a community-based study ofcardiovascular disease (CVD) risk factorsand cognive funconing were put through

a series of brain and cognive challengesto assess their visual-spaal, verbal and

working memory, scanning tracking andexecuve funcon. Those who scored thehighest across all tests consumed the mostmilk and dairy products, the study found.

Cognive performance scores increasedlinearly across increasing categorical levels of

dairy food intake for 7 out of 8 outcome meas-ures. Milk drinkers also maintained healthierdiets overall compared to non-drinkers.

Frequent dairy food intake was associ-ated with beer cognive performanceacross a range of cognive domains in thisdemena-free, community dwelling popu-laon, the authors said. The associaonbetween greater dairy food intake and beer

cognive performance remained signicanteven aer adjusng for several cardiovas-cular risk factors such as CVD prevalence,hypertension and wait circumference.

While the authors said the study has a num-ber of strengths, including large communitysample, longitudinal studies are sll neededto improve understanding of the associaonbetween dairy intake and cognive funcon.

As brain disorders are most likely to impactupon more than a single cognive abilityor behavior, cognive funcon needs to beassessed with a thorough neuro-psychologicaltest measuring a range of cognive abilies.

Frequent intake of dairy products suchas milk, cheese and yoghurt has also beenshown to help reduce weight and con-trol blood pressure and diabetes, all of

which are risk factors for CVD that increasethe likelihood of cognive dysfuncon.


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34 15-31 March 2012 In Pract ice

Management of CHF in primary care

Dr. David SimConsultant, Department of Cardiology

Co-Director, Heart Failure Programme

Naonal Heart Centre Singapore

Impaired pumping ability

Congesve heart failure (CHF) theinability of the heart to pump oxygen-

rich blood sucient to meet the bodysmetabolic needs is a clinical syndromeaccompanied by derangement in the neu-rohormonal system, the renin-angioten-

sin-aldosterone system and sympathecsystem.

Common causes of heart failure include

ischemic heart disease, cardiomyopa-thy and hypertension. Other causes arealcoholic cardiomyopathy, valvular heartdisease, thyrocardiac disease, chemother-apy-induced cardiomyopathy and viralmyocardis and in rare cases, hemochro-matosis and amyloidosis.

When cardiac muscles are damaged, itmakes the heart less able to pump blood.

Fluid accumulates in the lungs, in theabdomen, or in the peripheral ssues, acondion called uid overload.

Diagnosing CHF

With proper history taking coupled withcomprehensive physical exam, physiciansare able to get a diagnosis. Echocardiogrammay be useful but not essenal for CHF

diagnosis. A simple chest X-ray can detectcongeson in the lung. Jugular venous

pressure is oen assessed as a marker of

uid status. Blood tests performed includeelectrolytes, renal funcon and liver

CHF is the end result of a variety of insultsto the heart which in some cases may beirreversible.


35/46


funcon tests. The serum level of B-typenatriurec pepde (BNP) or N-terminal prob-type natriurec pepde or (NT-proBNP)is related to the severity of heart failure.

Higher levels of BNP or NT-proBNP areassociated with bad prognosis.Symptoms of CHF depend on the side

of the heart involved. In le-sided fail-ure, congeson of pulmonary vascula-ture causes respiratory symptoms such as

dyspnea on exeron or at rest, orthopnea increasing breathlessness on lying at and paroxysmal nocturnal dyspnea. Easy

fague and hypotension are signs of poorcardiac output.

In right-sided failure, there is venouscongeson leading to uid accumulaonin the feet and ankles. Ascites and hepa-tomegaly may also occur in progressivelysevere cases. Liver congeson may resultin liver funcon impairment. Jaundice andderanged clong may also occur.

Paents with biventricular failure oenpresent with both le and right-sidedsymptoms.

Clinical Guidelines

Physicians can refer to the American

Heart Associaon (AHA), the AmericanCollege of Cardiology (ACC) and theEuropean Society of Cardiology (ESC)

guidelines for managing heart failure.Angiotensin-converng enzyme inhibi-tors (ACE inhibitors)/angiotensin recep-tor blockers (ARBs) and beta-adrenergicblockers (beta-blockers) are the corner-

stone of treatment in paents with heartfailure and a reduced le ventricularejecon fracon (LVEF). Use of aldoster-one antagonists is recommended in New

York Heart Associaon (NYHA) Class III/IVpaents with LVEF of


36/46


42 percent in paents with mild symptoms(Class II). The incidence of gynecomasa seen with spironolactone is also lower.

For Class III or IV paents, we use spirono-

lactone based on the RALES trial.Another drug available is ivabradine,which in the SHIFT-HF trial was shown todecrease mortality when added to stand-ard therapy of ACE inhibitors/ARB andbeta-blockers. Ivabradine is recommendedin paents with sinus rhythm with a heartrate of >70 beats per minute.

Challenge to GPsCHF is the end result of various insults

to the heart which in some cases may be

irreversible.The key message for GPs is not just to

treat CHF as a simple uid overload issue.Paents oen have other co-morbidiessuch as renal impairment, anemia, sleep

apnea and depression. All paents with

newly diagnosed heart failure should bereferred for further evaluaon. Once sta-ble, paents can be managed in the pri-mary care seng.

Some paents may present withoutsymptoms (NYHA Class I) but succumb tosudden cardiac death. The most commonreasons for this are ventricular tachycar-dia (VT) and ventricular brillaon (VF) in

paents with poor ejecon fracon. In thiscase, implantable cardioverter debrilla-tor (ICD) improves survival.

Paents younger than 60 years old,with symptoms that do not improvedespite opmal medical therapy, shouldbe referred to us for transplant.

New advances in CHF treatment

Recently, the lack of good, healthyheart transplant donors has seen the

need to improve the current generaonof mechanical heart devices. The widen-ing gap in the number of paents await-ing transplantaon and hearts available

for transplant has prompted eorts tomake the current generaon of ventricu-lar assist devices (VAD) smaller, more con-venient and totally implantable. Devicetherapy has started to play in selectedpaents with CHF. The challenge now forcardiologists is how to get rid of the drive-line to eliminate potenal source of infec-on. If the pump technology improves to a

stage that survival with VAD is equivalentto heart transplantaon, then transplanta-on may be replaced by VAD.

Stem cell therapy is also being tested.This and other signicant advances in drugtherapy have sparked an unprecedentedopmism in the treatment of CHF. We, atthe Naonal Heart Centre, Singapore, areacvely taking part in clinical trials and are

awaing eagerly the results of other big-ger studies.

CHF is a debilitang if not fatal condi-on with lots of burden on the paent, thefamily, livelihood and the health care sys-tem. We need a mul-approach to tacklethis problem.

Online Resources:American Heart Associaon

www.american heart.org/heart failure

Heart Failure Maers

www.hearailuremaers.org

European Society of Cardiology

www.escardio.org/communies/HFA/Pages/

welcome.aspx


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37 15-31 March 2012 After Hours

Autumn in

KyotoChrisna Lau discovers autumn colorsinKyoto,Japan,whenmapleleaveswere

turningredinmid-November.

The Japanese term momijigari (red-leaf hunting) vividly describes the

character o the

countrys maple leaves in

autumn. Despite meticu-

lous orecasts o when the

leavesaregoingtoturnred

indierent partsofJapan,

whether you catch them


38/46

38 15-31 March 2012 After Hours

Autumn in

Kyotointheirmostvibrantcolorsisamatterof

luck.

With the forecast that Kyoto leaves

were going to start turning red in early

November,wesetohopingtoseestun-

ningseasofredatscenicspotsacrossthe

city by the middle o the month. But the

maple leaves were just starting to turn

red when we were in Kyoto.

The late arrival of autumn colors did

nothamperpeoplesspirits,asocksof

localandoverseastouristscouldbeseen

snappingpicturesofanyredleafinsight.

AtpopularattractionssuchastheKiyo-

mizu Temple (

) and the nearbyJishu Shrine (), young women

came in kimono (traditional Japanese

ull-length robes) to celebrate the oc-

casionandpraytothedeityofloveand

matchmakingsaidtoresideinthelatter.

Forabreakfromthecrowd,Sagano

()inthenorthwesternpartofthe

city oers tranquility at temples built

more than 1,000 years ago. Many o the

templeshousesculpturesandscriptures

ocially classifed as National Treasures

andImportantCulturalPropertiesofJa-

pan. These temples are also fabulous

spotsforred-leafviewing,whereautumn

colorscomplementthebeautyofthear -

chitectureandtraditionalJapanesegar-

dens.

I you want to see autumn colors in

Kyoto,itisnottooearlytobookafewmonthsinadvance.Withthelargenum-

berofvisitorsockingtothecityinNo-

vember,most hotels and innswere full

whenwebookedinSeptember.


39/46

39 15-31 March 2012 Humor

Excessive consumption of seafood like lobster,for example, can increase bad cholesterol levels

or something much, much more serious!

I know your condition is very serious, but think of allthe other serious conditions you dont have!

Dont worry about the hallucinations youve beenhaving lately, its only your imagination!

Im the Doctor here, soI will decide if youre sick or not!

Hes going to live, but hestill thinks you should remarry! There you are. Been waiting long?


40/46

40 15-31 March 2012 Calendar

MALAYSIANEVENTS

March

1st World Congress

on Healthy Ageing 2012

19/3 to 22/3; Kuala Lumpur

Info : Secretariat

Tel : (03) 2070 5600

Fax : (03) 2072 5600

Email : [email protected]

www.healthyageingcongress.org

8th Naonal Symposium on Adolescent

Health (8th NSOAH)

23/3 to 25/3; Melaka

Info : Dr. N. Thiyagar / Dr. Mymoon Alias

Tel : (03) 20954784

Fax : (03) 20954784

Email : [email protected] /

[email protected]

Naonal TB Symposium 2012


Info :Dr. Liza Ahmad Fisal /

Dr. Nurhaya Mohd Marzuki /

Dr. Zamzurina

Tel : (03) 4023 2966

Fax : (03) 4024 4063

Email : [email protected] /

[email protected] /

[email protected]

www.naonaltbsymposium.webs.com

The First Internaonal Conference on

the Promoon of Mental Health and

Wellbeing28/3 to 30/3; Kuching

Info : Mr. Michael Murray

Tel : (082) 230 597


www.cliordbeersfoundaon.

co.uk

Internaonal Academy

of Periodontology 14th

Internaonal Convenon

and Annual Scienc Meeng

29/3 to 31/3; Kuching

Info : Dr. Ajay Kakar

Tel : (+91) 9821015579


www.perioiap.org

Endoscopy 2012


Info : MSGH SecretariatTel : (03) 4024 4700 / 4025 4700 /

4025 3700

Fax : (03) 40230 8100


www.msgh.org.my

AprilNutrion and Dietecs Professional

Competency Symposium


Info : Ms Grace Chong

Tel : (03) 2162 0566

Fax : (03) 2161 6560



41/46


19th Annual Congress of the Perinatal

Society of Malaysia

12/4 to 15/4; Petaling JayaInfo : Secretariat

Tel : (03) 2615 5555 / 2615 6889

Fax : (03) 2694 8187

Email :perinatalsocietymalaysia@

yahoo.com

www.perinatal-malaysia.org

Annual Scienc Meeng of the

Malaysian Society of Anaesthesiologists

& College of Anaesthesiologists,

AMM 2012

19/4 to 22/4; Kuantan

Info : Secretariat

Tel : (03) 4023 4700 / 4025 4700

Fax : (03) 4023 8100


www.msa.asm.org.my

6th General Assembly of Asia

Pacic Organizaon for Cancer

Prevenon (APOCP 2012)


Info : Professor Yip Cheng Har

Tel :(03) 7949 2440

Fax : (03) 7958 6360Email : [email protected]/ yipch@

ummc.edu.my

www.apocp.net

9th Malaysian Conference and

Exhibion on An-Aging, Aesthec,

and Regenerave Medicine & 2nd

Internaonal Congress on An-Aging,

Aesthec, and Regenerave Medicine27/4 to 29/4; Kuala Lumpur

Info : Secretariat

Tel :(03) 4041 0092 / 4041 6336

Fax :(03) 4042 6970 / 4042 7919Email : [email protected]

www.saaarmm.org

14th Johor Mental Health Convenon

27/4 to 28/4; Johor Bahru

Info : Pn. Noor Ratna /

Ms. Ng Yuen kwan

Tel : (07) 237 3333 Ext. 400 /

(07) 237 3333 Ext. 410

Fax : (07) 237 1396

Email : ohormentalhealth2012@gmail.

com

www.psychiatry-malaysia.org

WFAS 2012 Malaysia:

Acupuncture, Orthopedic,

Cancer and Educaon Symposium30/4 to 2/5; Kuching

Info : Professor Liao Chunhua

Tel : (03) 5510 6868 ext 683

Fax : (03) 9173 9369


www.msu.edu.my

May

Private Medical Praconers

Associaon of Selangor and Kuala

Lumpur 52nd AGM & Annual

Scienc Meeng


Info : Secretariat

Tel : (03) 4023 4700 / 4025 4700Fax : (03) 4023 8100

MALAYSIANEVENTS


42/46



www.pmpaskl.org

15th Malaysian Society

of Transplantaon Scienc

Meeng 2012


Info : Rohayah Hamzah

Tel : (03) 4024 1522

Fax : (03) 4022 6882


www.mst.org.my/main.html

South East Asia Internaonal

Team Implantology Annual

Secon Meeng 2012


Info : Dr. Lee Soon Boon

Tel : (03) 2095 1532 / 2095 / 1495

Fax : (03) 2094 4670Email : [email protected]

www.i.org

Malaysian Endocrine & Metabolic

Society Annual Congress (MAC 2012)

24/5 to 27/5; Kota Bharu

Info : Secretariat

Tel : (03) 7948 1888Fax : (03) 7948 1812


AGM/Annual Scienc Meeng

of the College of Surgeons,

Academy of Medicine of Malaysia

25/5 to 27/5; Kuantan

Info : Secretariat

Tel : (03) 4023 4700/4025 4700

Fax : (03) 4023 8100


www.acadmed.org.my

June

Royal College of Obstetricians

and Gynaecologists (RCOG)

10th Internaonal Scienc

Meeng 2012

5/6 to 8/6; Kuching

Info : Dr. Gunasegaran Rajan

Tel : (03) 6201 3009

Fax : (03) 6201 7009


www.rcog2012.com

4th Naonal Early Childhood

Intervenon Conference7/6 to 9/6; Sibu

Info : Dr. Toh Teck Hock

Tel : (084) 217 912

Fax : (084) 213 902

Emai : [email protected]

hp://agapesibu.org/necic2012/

4th Parenteral & Enteral Nutrion

Society of Malaysia (PENSMA) 2012

14/6 to 16/6; Penang

Info : Secretariat

Tel : (03) 4023 4700 / 4025 4700 /

4025 3700

Fax : (03) 4023 8100


www.PENSMA.org

MALAYSIANEVENTS


43/46


44/46


INTERNATIONALEVENTS

June

2012 Annual Meeng of American

Society of Clinical Oncology (ASCO)

1/6 to 5/6; Chicago, Illinois, US

Info : Secretariat


hp://chicago2012.asco.org/

10th Internaonal Conference of the

Asian Clinical Oncology Society13/6 to 15/6; Seoul, South Korea

Info : Secretariat

Email : [email protected] / scienc@

acos2012.org

www.acos2012.org

15th Internaonal Congress on Infecous

Diseases (ICID)13/6 to 16/6; Bangkok, Thailand

Info : Secretariat


www.isid.org/icid/

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45/46

Medical Editor Dr. Kumaran Ramakrishnan

Editorial Advisory Board - Malaysia

Hepatology Tan Sri Dato' Seri Dr. Mohd Ismail Merican

Cardiology Dato Dr. Khoo Kah Lin

Pantai Medical Centre

Clinical Oncology Assoc. Prof. Dato' Dr. Fuad Ismail

Hospital Universi

Kebangsaan Malaysia

Urology Prof. Dato Dr. SahabudinRaja Mohamed

Prince Court Medical Centre

Gastroenterology Prof. Dato Dr. Goh Khean Lee

University Malaya Medical Centre

ENT Prof. Dato Dr. Balwant Singh Gendeh

Hospital Universi

Kebangsaan Malaysia

Family Medicine Prof. Dan Dr. Chia Yook Chin

University Malaya Medical CentreEndocrinology Dr. Chan Siew Pheng

Sime Darby Medical Centre

Respiratory Datuk Dr. Aziah Ahmad Mahayiddin

Medicine Instute of Respiratory Medicine

Anesthesiology Prof. Dr. Ramani Vijayan


Infecous Diseases Prof. Dr. Adeeba Kamarulzaman


Psychiatry Prof. Dr. Mohamad Hussain Habil


O&G Dato Dr. Ravindran Jegasothy

Hospital Kuala Lumpur

Dermatology Dr. Steven KW Chow

Pantai Medical Centre

Genito-Urinary Dr. Doshi Hemendra Kumar

Medicine Klinik Kulit & Kelamin Shriji

Radiology Prof. Dr. John George

FRCR (UK)



46/46

Publisher : Ben YeoDeputyManaging Editor : Greg TownSenior Editor : Naomi RodrigContribung Editors : Chrisna Lau (Hong Kong),

Saras Ramiya, Leonard Yap,Pank Jit Sin, Malvinderjit KaurDhillon (Malaysia), Yves St.James Aquino, M.D.(Philippines), Radha Chitale,Elvira Manzano, Rajesh Kumar(Singapore), Hardini Arivian(Indonesia)

Publicaon Manager : Cliford PatrickDesigners : Nur Malathy, Donny Bagus,

Charity Chan, Lisa LowProducon : Jasmine ChayCirculaon Execuve : Judy LeeAccounng Manager : Minty KwanPublicaon Assistant : Rachael TanPublished by : UBM Medica Pacic Limited

27th Floor, OTB Building160 Gloucester Road, Wanchai, HongKongTel: (852) 2559-5888 Fax: (852) 2559-6910Email: [email protected] Enquiries:

China : Teo Wai Choo

Tel: (8621) 6157 3888Email: [email protected] Kong : Connie Ho, Krisna Lo-Kurtz,

Marisa Lam, Miranda WongTel: (852) 2559 5888Email: [email protected]

India : Monica BhaaTel: (9180) 2349 4644Email: [email protected]

Indonesia : Cliford Patrick, Ria Pamolango, HaaHasibuan, Sri DamayanTel: (6221) 729 2662Email: [email protected]

Japan : Mamoru Takagi

Tel: (813) 5562 6961Email: [email protected] : Kevin Yi

Tel: (822) 3019 9350Email: [email protected]

Malaysia : Irene Lee, Lee Pek Lian, Grace Yeoh,Sumitra PakryTel: (603) 7954 2910Email: [email protected]

Philippines : Marian Chua Julie Mariano Kims Pag-


Thailand : Wipa SriwijitchokTel: (662) 741 5354Email: [email protected]

Vietnam : Nguyen Thi Lan Huong, Bui Thi Cam TrucTel: (848) 3829 7923Email: [email protected]

Europe/USA : Krisna Lo-Kurtz, Maria KaiserTel: (852) 2116 4352Email: [email protected], [email protected]

Medical Tribune is published 12 mes a year (23 mesin Malaysia) by UBM Medica, a division of UnitedBusiness Media. Medical Tribune is on controlledcirculaon publicaon to medical praconers in Asia.It is also available on subscripon to members of alliedprofessions. The price per annum is US$48 (surfacemail) and US$60 (overseas airmail); back issues at US$5per copy. Editorial maer published herein has beenprepared by professional editorial sta. Views expressedare not necessarily those of UBM Medica. Although greateort has been made in compiling and checking theinformaon given in this publicaon to ensure that it isaccurate, the authors, the publisher and their servants oragents shall not be responsible or in any way liable for theconnued currency of the informaon or for any errors,omissions or inaccuracies in this publicaon whetherarising from negligence or otherwise howsoever, orfor any consequences arising therefrom. The inclusionor exclusion of any product does not mean that thepublisher advocates or rejects its use either generallyor in any parcular eld or elds. The informaoncontained within should not be relied upon solely fornal treatment decisions. 2011 UBM Medica. All rights reserved. No part of thispublicaon may be reproduced in any language, storedin or introduced into a retrieval system, or transmied,in any form or by any means (electronic, mechanical,photocopying, recording or otherwise), without thewrien consent of the copyright owner. Permissionto reprint must be obtained from the publisher.Adversements are subject to editorial acceptance andhave no inuence on editorial content or presentaon.UBM Medica does not guarantee, directly or indirectly,the quality or ecacy of any product or service describedin the adversements or other material which iscommercial in nature.

Philippine edion: Enteredas second-class mail at theMaka Central Post Oceunder Permit No. PS-326-

d d b

Publisher : Ben YeoDeputyManaging Editor : Greg TownSenior Editor : Naomi RodrigContribung Editors : Chrisna Lau (Hong Kong),

Saras Ramiya, Leonard Yap,Pank Jit Sin, Malvinderjit KaurDhillon (Malaysia), Yves St.James Aquino, M.D.(Philippines), Radha Chitale,Elvira Manzano, Rajesh Kumar(Singapore), Hardini Arivian(Indonesia)

Publicaon Manager : Cliford PatrickDesigners : Nur Malathy, Donny Bagus,

Charity Chan, Lisa LowProducon : Jasmine ChayCirculaon Execuve : Chrisne ChokAccounng Manager : Minty KwanPublicaon Assistant : Rachael TanPublished by : UBM Medica Pacic Limited

27th Floor, OTB Building160 Gloucester Road, Wanchai, HongKongTel: (852) 2559-5888 Fax: (852) 2559-6910Email: [email protected]

Adversing Enquiries:China : Teo Wai Choo

Tel: (8621) 6157 3888Email: [email protected] Kong : Connie Ho, Krisna Lo-Kurtz,

Marisa Lam, Miranda WongTel: (852) 2559 5888Email: [email protected]

India : Monica BhaaTel: (9180) 2349 4644Email: [email protected]

Indonesia : Cliford Patrick, Ria Pamolango, HaaHasibuan, Sri DamayanTel: (6221) 729 2662Email: [email protected]

Japan : Mamoru Takagi

Tel: (813) 5562 6961Email: [email protected] : Kevin Yi


Malaysia : Irene Lee, Lee Pek Lian, Grace Yeoh,Sumitra PakryTel: (603) 7954 2910Email: [email protected]

Philippines : Marian Chua Julie Mariano Kims Pag-


Thailand : Wipa SriwijitchokTel: (662) 741 5354Email: [email protected]

Vietnam : Nguyen Thi Lan Huong, Bui Thi Cam TrucTel: (848) 3829 7923Email: [email protected]

Europe/USA : Krisna Lo-Kurtz, Maria KaiserTel: (852) 2116 4352Email: [email protected], [email protected]

Medical Tribune is published 12 mes a year (23 mesin Malaysia) by UBM Medica, a division of UnitedBusiness Media. Medical Tribune is on controlledcirculaon publicaon to medical praconers in Asia.It is also available on subscripon to members of alliedprofessions. The price per annum is US$48 (surfacemail) and US$60 (overseas airmail); back issues at US$5per copy. Editorial maer published herein has beenprepared by professional editorial sta. Views expressedare not necessarily those of UBM Medica. Although greateort has been made in compiling and checking theinformaon given in this publicaon to ensure that it isaccurate, the authors, the publisher and their servants oragents shall not be responsible or in any way liable for theconnued currency of the informaon or for any errors,omissions or inaccuracies in this publicaon whetherarising from negligence or otherwise howsoever, orfor any consequences arising therefrom. The inclusionor exclusion of any product does not mean that thepublisher advocates or rejects its use either generallyor in any parcular eld or elds. The informaoncontained within should not be relied upon solely fornal treatment decisions. 2012 UBM Medica. All rights reserved. No part of thispublicaon may be reproduced in any language, storedin or introduced into a retrieval system, or transmied,in any form or by any means (electronic, mechanical,photocopying, recording or otherwise), without thewrien consent of the copyright owner. Permissionto reprint must be obtained from the publisher.Adversements are subject to editorial acceptance andhave no inuence on editorial content or presentaon.UBM Medica does not guarantee, directly or indirectly,the quality or ecacy of any product or service describedin the adversements or other material which iscommercial in nature.

Philippine edion: Enteredas second-class mail at theMaka Central Post Oceunder Permit No. PS-326-

d d b

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Medical Tribune March 2012 MY2

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