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No secret to South Korea’s success in the medical field

MALAYSIA FOCUS

Hair today, gone tomorrow

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1-15 June 2012

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1-15 June 20123

No secret to South Korea’s success in the medical fieldPank Jit Sin

South Korea’s success in the field of med-icine can be attributed to sacrifice and hard work, says Professor Sim Kui Hian.

Speaking at a panel discussion during the recent National Heart Association of Malay-sia (NHAM) Annual Scientific Meeting, Sim, president of NHAM, said that the South Kore-ans have invested a lot in terms of money and commitment to arrive at what they are today. Sim was chairing a session on late-breaking trials from conferences around the world. He was responding to Professor Wan Azman Wan Ahmad’s earlier call for Malaysian doc-tors to step up and improve the standard of medicine in our country.

Professor Wan Azman Wan Ahmad had earlier mentioned of the South Koreans’ im-provements in medical field. He said that both Malaysia and South Korea were on equal footing during the early 1970’s. However, the situation has changed in recent times as their medical advancement has since surpassed ours. Wan Azman, professor, department of medicine, University of Malaya, was discuss-ing two late-breaking trials of South Korean origin and both were investigator initiated tri-als.

In presenting the excerpts from the American College of Cardiology’s late breaking trials, Wan Azman said he hoped Malaysian doctors would be able to have the opportunity and privilege to present at the international arena (eg, late break-ing trials session of the ACC).

The South Korea study in question is the HOST-ASSURE clinical trial, which was an investigator-initiated study, involving 40 car-diac centers nationwide. Azman noted that data collection was done in an exemplary manner and the trial was concurrently pub-lished in the New England Journal of Medicine.

Sim recalled his communication with a South Korean counterpart on a recent visit to the country. The doctor had been unable to find time to visit his ailing mother who lived a short distance away. He said that a typical day at work began at 6 in the morning (which meant that they had to leave home a little af-ter 5 am). “This was followed by the usual meetings, ward visits, surgeries, consultation and paperwork, which would usually end at 6. The day would usually end for most of us here, but it’s far from over for our Korean counterparts.”

After work and a short dinner, the team of cardiologists will gather to discuss clinical trial data and to design new trials. This goes on past midnight before they are able to pack up for home.

The South Korean’s venture into clinical trials can be attributed to their government policy – 5 years ago, their Ministries of Fi-nance, International Trade, Environment and Health formed a task force to promote clinical research.

In Malaysia, the MOH set up the Clinical Research Malaysia Unit to promote clinical research in the country as part of the Econom-ic Transformation Policy.

Forum1-15 June 20124

Responding to the increasing threat of TB: Malaysia’s battle planExcerpted from the keynote address by the Minister of Health Malaysia, Dato’ Sri Liow Tiong Lai, on the occasion of World TB Day 2012, Kuala Lumpur, 24 March.

Nations of the world celebrated the first World Tuberculosis (TB) Day, which was sponsored by the WHO

and the International Union against Tubercu-losis and Lung Disease (IUATLD) in 1982.

The intent of the event was to educate the public about the serious health and economic consequences of TB. The first World TB Day also coincided with the centennial anniversa-ry of the discovery of the bacteria that causes TB by Dr. Robert Koch in 1882. His discovery was considered to be the most important step towards the control and elimination of this deadly disease.

In 1993, the WHO declared TB ‘A Global Emergency.’ This much-feared disease is an ancient killer and can be traced back to the Neolithic Age, thousands of years ago. Dur-ing the 17th and 18th centuries, TB caused up to 25 percent of all deaths in Europe. Up to the first half of the 20th century, no effective treat-ment was available until streptomycin was introduced in 1946.

TB will claim the lives of more than four million women between now and 2015, leav-ing millions of children orphaned. There are nine million new cases reported globally each year, and 1.7 million people around the world will die of TB each year – equivalent to 4,600 deaths per day! If left untreated, a TB patient can infect 10 to 15 people in a single year.

Unfortunately, despite our gallant efforts, TB still remains with us and is becoming more lethal. Globally, TB is among the three top

causes of death amongst women aged 15 to 44 years. In Malaysia, it is the number one cause of death amongst all reported infectious dis-eases. Alarmingly, more than three-quarters of all TB cases affect people between 15 and 54 years of age, those in their prime, productive years. Consequently, this disease is a potential cause of poverty for affected individuals and their families.

Malaysia is experiencing an upward trend in the number of TB cases. In 2011, 20,666 cases were reported, a 7 percent increase compared with 19,337 cases for the previous year. The MOH is working diligently towards reducing the disease burden and is hopeful of eliminat-ing TB by 2050. The UN has announced the Millennium Development Goal Number 6, which is combating HIV/AIDS, malaria and other diseases. Target 8 is: “To have halted by

The only way to keep TB from spreading is early detection and treatment.

Forum1-15 June 201252015 and begun to reverse the incidence of ma-laria and other diseases such as TB.”

How are we going to combat TB? The MOH has developed a 5-year National Strategic Plan to be implemented from 2011 to 2015. More health facilities are being made available for diagnostic and treatment purposes, so that pa-tients with TB are detected and treated early. Patient compliance to treatment and follow-up are also key issues that will be addressed. Commitment to the treatment that is planned and customized for the patient is paramount. Our fight against this disease requires consid-erable support, not just from the government and NGOs, but from our patients and their families as well.

Awareness campaigns on the possibility of TB as a cause of chronic cough must be imple-mented. As the experts say, “Think of tubercu-losis if you have persistent cough. Come to us for screening if you have persistent cough, loss of appetite, weight-loss or night sweats. Do not hesitate! Screening and treatment are free-of-charge.”

I would like to emphasize that TB can be cured. It takes teamwork involving the patient,

the healthcare team, the family and the com-munity. It has been scientifically proven that after 2 weeks of intensive treatment, a TB pa-tient can be rendered non-infectious. All that is needed is to ensure patient compliance. This can be achieved by a committed caregiver – either a healthcare worker or a trained family member who is responsible for ensuring that ‘Directly Observed Therapy, Short-course’ (DOTS) is practiced.

DOTS requires the patient to be observed directly each time he/she takes the medication during the 6-month period of treatment. It is ac-knowledged that it is not easy to religiously take medication, especially when one feels ‘better’ after several weeks of treatment. However, one needs to realize that to be completely free of the disease, compliance to treatment is extremely important. Failure to comply will mask the dis-ease and it will reappear in the future when the immune system is vulnerable.

Every step we take will be an important one for our nation as we endeavor to reduce the incidence and burden of TB. If we do not act now, we will deprive our future generations of their health. The time to act is now. MT Pharmaniaga Plecaz_1_3 column.ai 1 1/5/12 11:19 AM

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1-15 June 20127 Medica l B r ie fs

Shisha smoking carries many of the same health risks as cigarettes, in-cluding cancers of the oral cavity,

lung, stomach, esophagus and reduced fertility, according to Singapore’s Health Promotion Board (HPB).

However, there appears to be a per-ception amongst some Singapore youth in particular that it is safer than regular tobacco cigarette smoking. The HPB has suggested this may be due to the fruity smell of the shisha smoke, the lack of a tobacco after-taste, as well as misinforma-

tion provided by shisha retailers.To counter the misinformation, the

board recently launched Singapore’s first shisha awareness campaign. About a dozen local and international youth advocates walked the Kampong Glam streets to raise awareness about the ills of shisha smok-ing. The event was organized by the HPB in conjunction with the 15th World Confer-ence on Tobacco or Health (WCTOH) as part of its ‘Live It Up Without Lighting Up’ (LIUWLU) Global Movement.

Shisha smoking not safe

Diabetic limb salvage rate improves at CGH

Diabetic limb salvage rates at Sin-gapore’s Changi General Hospi-tal (CGH) rose to over 90 percent

among certain patients who received artery opening endoscopic surgery using drug eluting balloons, according to an in-hospi-tal survey.

The figure, based on follow-up data from 30 patients treated with drug eluting balloons, is an improvement over rates of limb salvage from 1 year ago, which were between 70 and 80 percent.

Diabetic patients are at significant risk of amputation due to narrowed arteries, infection and untreated ulcers in their extremities, particularly in the feet and

legs. “In a select group of patients we have managed to save these diabetic feet from amputation,” said Dr. Steven Kum, a vas-cular and endovascular consultant at CGH.

The drug eluting balloons mechanically widen narrowed arteries and impregnate the arterial walls with drugs to prevent scarring and restenosis, although the medi-cine has no effect on calcium deposits. Al-though most patients would benefit from balloon angioplasty, Kum said early results from their survey showed that arteries from three-quarters of patients who underwent drug eluting balloon angioplasty remained open at 3 months post-procedure.

Malays ia Focus1-15 June 20128National Heart Association of Malaysia Annual Scientific Meeting 2012, 12-15 April

Opinions differ on fitness testing before onset of vigorous exercisePank Jit Sin

There are various – and conflicting – recommendations on testing the fitness of individuals prior to vigorous exercise. This

is due, in part, to the lack of evidence, says a car-diologist.

Those who are eager to begin a vigor-ous exercise regime are usually advised to consult their doctors, but there are conflicting recommendations by different heart and sports associations.

The American College of Cardiology (ACC) and the American Heart Association (AHA) recommend stress testing for asymptom-atic persons with diabetes mellitus if they are about to embark on vigorous exercise, said Dr. Chong Wei Peng, a senior consul-tant cardiologist. (ACC/AHA 2002 Guideline Update for Exercise Testing: Summary Article circ.ahajournals.org/content/106/14/1883.full Accessed on 15 May 2012) This recommenda-tion extends to asymptomatic men above 45 and women above 55.

“They [the ACC and AHA] place importance on diabetes and age, both of which are strong predictors of coronary artery disease.”

However, the American College of Sports Medicine (ACSM) has a lower threshold for stress testing, and it includes moderate exercise eg, brisk walking. This is extended to include men above 45 and women above 55. Those who have more than two risk factors for coronary artery disease

are also in the recommended testing group. On the other hand, the US Preventive Ser-

vices Task Force, a panel of independent ex-perts that makes recommendations based on evidence-based medicine, does not recom-mend any stress testing at all, said Chong.

“The discrepancies [on testing] are clearly caused by a lack of evidence from random-ized control trials on what is the appropriate strategy [in such a situation],”said Chong.

Even with this ambiguity and uncertainty, Chong said the benefits of exercise outweigh its risks. “Screening need not be complicated. A simple echo-cardiogram and occasionally stress testing in patients who require it is suf-ficient in most cases.”

Special consideration has to be given to those with intermediate-to-high cardiac risks. These patients have an exercise capacity of below six Metabolic Equivalent Tasks (METs) and exhibit ischemia at workloads of below six METs. They would also exhibit a fall in systolic blood pressure and, possibly, undergo ventricular tachycardia. All these symptoms would strongly suggest that such patients have underlying cardiac disease.

In young patients, especially those below 30, several conditions could cause cardiac death as well, including hereditary heart disease, cardiomyopathy, myocarditis, Mar-fan syndrome and valvular heart disease. Hence, physicians should screen those suspected to have these conditions.

Malays ia Focus1-15 June 20129

AEDs may help reduce sudden cardiac deathNational Heart Association of Malaysia Annual Scientific Meeting 2012, 12-15 April

Pank Jit Sin

Having a sports arena-based automat-ed external defibrillator (AED) can increase the likelihood of survival

for athletes, says a cardiologist. AEDs are an important apparatus to have

around a sports arena as “the majority of sud-den cardiac deaths in athletes manifest as ma-lignant arrhythmias during or immediately after exercise,” said Dr. Hasral Noor Hasni, of the National Heart Institute.

An important factor contributing to the survival of an athlete suffering from cardiac arrest is the amount of time taken from the point of arrest to the delivery of shock and cardiopulmonary resuscitation, said Hasral.

In this regard, AEDs are able to administer shock much sooner than waiting for the ath-lete to be brought to a hospital or waiting for an emergency team to arrive. With this in con-sideration, Hasral said it is “probably a good idea to equip sports arenas” with AED units.

The rate of sudden cardiac death in athletes is extremely rare, and according to an Italian registry, the incidence is 2.3 per 100,000 per-sons in the age group of 12 to 35 years. [Am Coll Cardiol 2003;42:1959-63] Different groups are more prone to different causes of cardiac death – African Americans are more prone to

structural heart disease or cardiomyopathy while Caucasian deaths are usually attributed to ion channelopathies.

Hasral, in his presentation on risk strati-fication of cardiac disease in competitive athletes, said that the most common cause of death in young athletes is hypertrophic obstructive cardiomyopathy while athletes in their middle age are more prone to coronary artery disease.

Being diagnosed with a cardiac condition is not necessarily the end of an athlete’s career, but he or she may need to switch to a more suit-able sport ie, one that is less strenuous.

About AEDs AEDs are so called as the electrode pads

are applied to the bare chest of the victim. This is in comparison with the internal defi-brillators, which have surgically implanted electrodes. As it is automated, AEDs require minimal training to use. The units are able to analyze the patient’s condition, and assist the person using the device via spoken prompts or visual displays.

In the US, a person using the AED is pro-tected by the Good Samaritan law. [www.ncsl.org/issues-research/health/laws-on- cardiac-arrest-and-defibrillators-aeds.aspx Accessed on 15 May]

Malays ia Focus1-15 June 201210

Heart failure in elderly poses unique challenge

National Heart Association of Malaysia Annual Scientific Meeting 2012, 12-15 April

Leonard Yap

Heart failure in the elderly presents itself differently, and may pose a challenge for the doctors to manage these pa-

tients, says an expert. “These patients usually have multiple comor-

bidities, which makes the treatment and man-agement of heart failure more complicated than in younger patients,” said Dr. Michel Komajda, professor of cardiology, University Pierre et Ma-rie Curie-Paris 6, and head of the cardiovascular and surgical departments, Pitié Salpetrière Hos-pital in Paris, France.

Elderly patients, defined as those aged 80 and above, suffer from a myriad of co-existing condi-tions, which include atrial fibrillation, hyperten-sion, diabetes, stroke and cognitive disorders/confusion. [Am Heart J 2000;139:85-93, Eur Heart J 2006;27(22):2725-36]

“We find a significant number of these pa-tients with renal failure, severe anemia, infection or cognitive disorders which make the manage-ment of the condition more complicated.” [Eur Heart J 2006;27(22):2725-36]

“Another reason why heart failure is differ-ent in the elderly is that in many instances there is a different pathophysiology.” The elderly are more likely to have preserved/normal left ven-tricular ejection fraction (≤45 percent) compared with younger patients. These patients were also more likely to have hypertension, but less likely to have coronary artery disease. [J Am Coll Car-diol 2003;41:1519-22]

All this information is very useful, but “how

can we improve implementation of [clinical practice] guidelines for doctors, in particular GPs and geriatricians?”said Komadja.

This can be done by creating simplified, pocket versions of these guidelines. In addition, patients should receive both verbal and written instructions on their management, be given a simplified treatment regimen, be provided with reminders whenever possible, and “improving the availability of healthcare providers by prop-er collaborations between cardiologists, GPs, nurses, geriatricians and, most importantly and particularly, if there are cognitive disorders, we should inform actively the family in the man-agement of medications,” Komajda said. [ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008, www.es-cardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-HF-EJHF.pdf Accessed on 11 May]

A meta-analysis of 33 studies found that mul-tidisciplinary management of elderly patients reduced mortality from heart failure by 20 per-cent. [Eur J Heart Fail 2005;7:1133-44]

The prevalence of heart failure among the el-derly increases significantly from under 10 per-cent in people aged between 70 and 74 to about 20 percent in people above the age of 85. [Am J Cardiol 2001;87:413-9]

People aged 80 or older currently constitute more than 3 percent of the population of North-ern America and almost 3 percent of the popula-tion of Europe, compared with less than 0.9 per cent in Asia, Latin America and the Caribbean, and less than 0.4 per cent in Africa.

Malays ia Focus1-15 June 201211A regional difference is projected to persist

over the next 50 years. By 2050, one in 10 indi-viduals will be aged 80 or older in the more de-veloped regions, while the corresponding ratio will be one in 30 in the less developed regions.

In comparison, in the least developed coun-tries, only one in 100 persons will be 80 or over.

In 2050, 19 countries, most of which are in Eu-rope, are projected to have at least 10 percent of their population aged 80 years or over. [De-mographic Profile of The Older Population, www.un.org/esa/population/publications/worldageing19502050/pdf/90chapteriv.pdf Accessed on 11 May]

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Hair today, gone tomorrowMalvinderjit Kaur Dhillon

Androgenetic alopecia (AGA) is the most common form of hair loss and accounts for 95 percent of cases among

males between the age of 30 and 70, a study has found. [Mayo Clin Proc 2005;80(10):1316-22]

“If left untreated, AGA is known to progress over time as the hair at the temples recedes fur-ther. A central spur of hair is left at the front and a bald spot increases in size at the crown. Eventually, the areas of hair loss at the front and crown meet, and the top of the head be-comes increasingly bald. All that remains is a border of hair around the side and back of the head,” said Dr. Stephen Chow, a senior consul-tant dermatologist.

“However, men need not agonise over this condition. With the right treatment options, the loss of their ‘crowning glory’ can be man-aged and reversed,” explained Chow.

AGA progression is typically assessed using the Norwood-Hamilton scale, which assists in identifying the stages of hair loss and monitor-ing hair loss. Doctors can then advise men on treatment options based on the results of the evaluation.

Medical treatment options include topical minoxidil (2 percent or 5 percent), surgical pro-cedures (hair transplantation, scalp reduction and rotation flaps) or oral finasteride 1 mg. Non-medical treatment options include sham-poos, mousses, sprays, hair weaves, wigs and supplements.

Discussing the effectiveness of some of the treatment options, Chow said studies have shown that minoxidil decreased progression of hair loss and promoted regrowth by 90 per-

cent. [J Am Acad Dermatol 1987;16:677-85] The side-effects of minoxidil include scalp irrita-tion and facial hypertrichosis, especially in fe-males. [J Am Acad Dermatol 2004:50(4);541-53]

Two randomised double-blind 1-year trials found that finasteride, a potent 5-alpha reduc-tase type 2 inhibitor, improved scalp hair by all evaluation techniques at 1 and 2 years (P<0.001 versus placebo). Clinically significant increases in hair count, measured in a 1-inch circular area of balding vertex scalp, were observed with finasteride treatment. [J Am Acad Derma-tol 1998;39(4 Pt 1):578-89] However, a separate study showed that in the first year of treatment with finasteride 1 mg, a slightly higher propor-tion of finasteride than placebo subjects report-ed adverse drug-related experiences in sexual function. [Eur J Dermatol 2002;12(1):38-49]

Chow, who was speaking at the media launch of the AGA Education Campaign, re-minded men and their spouses not to opt for non-clinically proven alternatives as these could frustrate them due to their ineffec-tiveness. The AGA Education Campaign, launched by the Federation of Private Medical Practitioners’ Association of Malaysia (FPM-PAM) and the Malaysian Society for Hair Sci-ences (MSHS), and supported by Merck Sharp & Dohme, aims to educate the public on AGA and to spread the key message that the condi-tion is treatable by doctors.

As part of the educational campaign, clinics treating AGA will display the AGA sticker. Educational ‘take-away’ cards on the condition will be available at these clinics. There will also be public service announce-ments over the radio and on billboards to educate the public about AGA.

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Malays ia Focus1-15 June 201215

Activity modification, medications key to managing OA effectively

Saras Ramiya

Patients with osteoarthritis are best man-aged with a combination of activity modification and medications, says con-

sultant orthopedic surgeon Dr. Lee Joon Kiong.“Currently, there is no known cure for os-

teoarthritis. Treatment is aimed at educating patients; controlling pain; strengthening sur-rounding muscles; and improving joint mobil-ity, functional status and quality of life,” Lee said.

Osteoarthritis has previously been consid-ered a disease resulting from wear and tear of the joints. However, it can be more accu-rately described as a condition that is a result of various biochemical, biomechanical, in-flammatory and immunologic factors. [Curr Opin Rheumatol 2003;15:628-33] These factors can cause structural and functional failure of synovial joints with erosion and loss of articu-lar cartilage, meniscal degeneration and osteo-phytes. [Z Rheumatol 1999;58:142-7]

Osteoarthritis may be the result of primary idiopathic causes or genetically determined, or is secondary to other causes like intra-articular fracture, ligament injury, gout and rheumatoid arthritis, Lee said.

Signs and symptoms of osteoarthritis may be acute, chronic or acute on chronic. When hav-ing acute symptoms, patients present with pain, warm and tender joints, swelling, redness and limited range of movement while those with chronic disease also present with deformity and crepitus.

Osteoarthritis commonly affects sites such

as neck, lower back, knee, hip, fingers and big toe leading to pain in these areas. Pain and stiff-ness may also be felt in the shoulder, elbow, wrist and ankle. Patients with osteoarthritis have Heberden’s and Bouchard’s nodes, and osteophytes in the joints and these are usually evident on the x-ray. The disease may also affect the neck and lower back in conditions known as cervical and lumbar spondylosis, respectively, where bone spurs form around the facet joint and cause nerve impingement pain, Lee said.

According to MOH’s Clinical Practice Guide-lines on the Management of Osteoarthritis 2002, age is the most powerful predictor of osteo-

Dr. Lee Joon Kiong

Malays ia Focus1-15 June 201216

arthritis with the prevalence of osteoarthritis rising steeply with advancing age at all joint sites. The estimated prevalence of symptomatic knee osteoarthritis in populations above the age of 65 is 30 percent. [Veerapen K. Osteoarthritis – Asian Perspective. In: Howe HS, Feng PH, eds. Textbook of Clinical Rheumatology. Singapore Na-tional Arthritis Foundation; 1997:294-95, Veera-pen K. Epidemiology of Rheumatic Diseases in Malaysia. In: Nasution AR, Darwawan J, Isba-gio H, eds. Proceedings of the 7th APLAR Congress of Rheumatology. September 13-18, 1992:397-99; Bali, Indonesia]

The exact prevalence of osteoarthri-tis is difficult to determine because of lack of use of standardized criteria. In epide-miological studies, osteoarthritis is often described by x-rays but x-ray changes may not correlate with the clinical symptoms. Furthermore, osteoarthritis may be influenced by multiple factors including race, genetics, body build, obesity, gender, occupational use, repetitive use and previous injury, Lee said.

The treatment in general comprises firstly, modification of activities by minimizing pain-ful movement, mobilizing joints when the acute phase is over and protecting the joints and soft tissue, and secondly, medications, which include analgesics (non-opioid and opioid in the form of gel or plaster), anti-inflammatory medications (NSAIDs and COX-2 inhibitors), structure-modifying medications (glucos-amine sulphate and chondroitin sulphate), and intra-articular injections (steroids and hyal-uronic acid). Patients may also be advised to use physical treatment eg, cold pack to reduce the swelling and inflammation of the joints, Lee said.

For knee osteoarthritis, key primary pre-vention strategies include weight reduction

and avoidance of undue trauma during sports and repetitive knee bending during daily ac-tivities. These strategies help “reduce the me-chanical loading on the knees.”

With regard to surgery, arthroscopy, espe-cially in knee osteoarthritis, may be required to perform lavage (flushing and suction-ing debris from the knee joint) and debride-ment (trimming damaged cartilage and bone spurs). Knee replacement surgery is the last option because patients have to modify their activities and their quality of life may deterio-rate after the surgery.

Lee was speaking at the media launch of a new combination medication, naproxen/ esomeprazole magnesium, for the treatment of osteoarthritis.

Patients with osteoarthritis typically have hands with painful and swollen joints.

Relieves & SuppressesChesty Cough

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Malays ia Focus1-15 June 201218

Anemia – before, during, after pregnancyMalvinderjit Kaur Dhillon

One in three pregnant Malaysian women could suffer from iron-defi-ciency anemia as the problem is often

undiagnosed and untreated, leaving many mothers and babies grappling with long-term health consequences, says an expert. [Mal J Nutr 1997;3:83-90]

Pregnant women are predisposed to ane-mia as they need approximately 50 percent more iron as plasma volume, red blood cell (RBC) volume and hemoglobin mass increase disproportionately. Their daily standard re-quirement of iron should be increased from 15 to 27 mg/dl.

Unfortunately, most women begin their pregnancy without sufficient stores of iron to meet their body’s increased demands, leading to iron-deficiency anemia. This situation con-tinues even after delivery, said Dr. Premitha Damodaran, a consultant obstetrician and gy-necologist.

New mothers are at a higher risk of iron-deficiency anemia if they are anemic during the third trimester, experience excessive blood loss during delivery, have multiple births and are breastfeeding.

Symptoms of anemia may resemble oth-er pregnancy conditions such as paleness, tiredness, fatigue, lethargy and shortness of breath. Most women disregard these symp-toms and assume they are a normal part of pregnancy. Thus, anemia is often not iden-tified and treated. This can lead to severe complications like miscarriage, premature delivery, low birth weight, behavioral abnor-

malities in children, long-lasting develop-ment disadvantage compared to their peers and fatal programming of disease in later life, explained Premitha. [WHO Essential Care Practice Guide: Pregnancy, Childbirth and Newborn Care. 2000]

“Women should always ensure that their blood is healthy by conducting tests when they plan to get pregnant, during pregnan-cy, and 4 to 6 weeks after delivery. They can always stay on top of the game by acquiring sufficient amounts of iron from daily dietary and supplementation to increase blood he-moglobin levels,” said Premitha.

Women can prevent and manage anemia by increasing their intake of iron-rich foods such as poultry, green leafy vegetables, nuts, liver, whole grains, dried fruits such as prunes and raisins, beans, melons, seeds like sesame, and tofu.

However, diet alone may not provide all the vital nutrients to reduce the chances of mild anemia. Doctors routinely prescribe iron supplements to treat anemia. Patients are recommended to choose an iron formula-tion suited to their body to reduce common side effects such as constipation, nausea, vomiting and diarrhea. Supplements with a flavored coating can help mask the metallic taste of iron that some patients dislike.

Premitha, who was speaking at a media education workshop organized by Merck Consumer Healthcare, advised women to continue taking iron-rich foods and supple-ments until they stop breastfeeding or for 6 months after delivery, whichever comes later.

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Reg iona l1-15 June 201220

GPs challenged to take part in BPH care

Elvira Manzano

The Singapore Urological Association (SUA) is calling upon GPs to become more involved in the management of be-

nign prostatic hyperplasia (BPH), or enlarged prostate gland, which is highly prevalent in old-er men.

“GPs can manage BPH and we should en-courage this,” said Dr. Michael Wong, medical director and senior consultant at the Urology, Fertility and Gynaecology Centre, Mount Eliza-beth Hospital, and president of the SUA. “They should be given tools – questionnaires, guide-lines and illustrations – to diagnose and treat BPH in their clinics.”

The SUA recently conducted trainings for GPs on the use of the International Prostate Symptom Score (IPPS), an eight-question screening tool, for quick assessment of the severity of lower uri-nary track symptoms (LUTS) suggestive of BPH.

Each question is assigned 0 to 5 points, for a total of 35 points. A score of 0 to 7 means a pa-tient has mild symptoms, 8 to 19 means moder-ate symptoms, and 20 to 35, severe.

In Singapore, half of men older than 50, and as many as 90 percent of those above 80, have histological BPH. Despite SUA’s yearly remind-er on BPH, aging men are still failing consulta-tion, Wong said.

“Aging women suffer from menopause but consult their doctors early on. By contrast, aging men bury their heads in denial and refuse con-sultation until the condition has far advanced.” Wong added that patients would only visit their doctors when symptoms have become bothersome and have already affected their quality of life.

The most common symptoms of BPH in-volve changes or problems with urination such as nocturia, hesitancy, straining, inter-mittency, dribbling, incomplete emptying and weak stream.

Wong said that if detected early, patients can benefit from pharmacologic agents such as 5 alpha-reductase inhibitors (5ARIs) and alpha-blockers. Studies have shown that early treatment with 5ARIs and alpha-blockers im-proved urinary symptoms in men with BPH. It also eliminated the need for hospitalization and surgery.

Dr. Lim Kok, organizing chair of Uro-fair 2012, said men with BPH need not suf-fer in silence and put up with a poor quality of life.“Visit your GPs and ask for the IPPS questionnaire. Early intervention using the IPPS will also spare hospitals from being bur-dened.”

Patients with complicated BPH, including those with acute urinary retention, recurrent urinary tract infection and hematuria, should quickly be referred to urologists.

GPs are capable of managing BPH and should be encouraged to ask their older male patients to undergo treatment before it affects their quality of life.

Reg iona l1-15 June 201221

Radha Chitale

The novel drug combination of estra-diol and dienogest is now available in private clinics in Singapore for use in

the treatment of heavy menstrual bleeding (HMB).

This product has been shown to reduce the incidence of HMB by more than 80 per-cent compared with placebo.

HMB affects up to 30 percent of wom-en and can severely impact quality of life through long periods of bleeding that can be heavy enough to cause anemia or require a blood transfusion, in severe cases.

“Many [affected] women suffer in silence because they do not know the difference be-tween a normal period and excessive men-strual blood loss, or they do not realise that it can be treated,” said Dr. Fong Yoke Fai, Head of the benign gynaecology division in the de-partment of obstetrics and gynaecology, Na-tional University Hospital, and president of the Obstetrical and Gynaecological Society of Singapore.

Two trials including 421 women aged at least 18 years old with heavy, prolonged or frequent bleeding were randomized to estra-diol/dienogest or a placebo for seven men-strual cycles. [Fertil Steril 2009;92:S32; Int J Gynecol Obstet 2009;107(suppl 2):S183]

HMB was defined as 80 mL or more of blood loss.

Complete symptom relief occurred in 29.2 and 29.5 percent of the treatment groups in each study compared with 2.9 and 1.2 per-cent of the placebo groups during a 90-day efficacy assessment phase.

Active treatment resulted in 88 percent less menstrual blood loss than placebo, and iron levels among the treatment groups improved significantly (P<0.0001 for both).

The drug is not recommended for women with cardiovascular problems and its efficacy among women with BMI over 30 is untested.

“Not only does [estradiol/dienogest] offer women rapid, significant and sustained reduction in menstrual blood loss, it also has a good bleeding profile,” said Professor Ian Milsom, professor of obstetrics and gynaeco-logy at Sahlgrenska University Hospital in Gothenburg, Sweden.

It is currently is available at private gynecology and GP clinics, but Dr. Axel Bouchon, general manager for Bayer Health-Care, Singapore, said the drug should be available through government hospitals with-in 6 months.

Estradiol/dienogest is now available in private gynecology and GP clinics.

New treatment option for HMB now available

Reg iona l1-15 June 201222

Compact CPAP device for OSA launchedElvira Manzano

A novel continuous positive airway pressure (CPAP) device for ob-structive sleep apnea (OSA) is now

available in Singapore.The device, known as Transcend®, is a rela-

tively light and compact CPAP machine, mea-suring only 16x9x7cm and weighing 400 grams. According to Somnetics, it is the only device of its kind using heat moisture exchange (HME) technology.

Approved by the US FDA last year, it is indi-cated for use in the treatment of patients with OSA, a chronic condition characterized by ab-normal pauses in breathing or instances of ab-normally low breathing during sleep.

Individuals with this condition suffer from disturbed sleep and sub-optimal oxygenation, leading to daytime sleepiness and lethargy.

“We are now pleased to launch [Transcend] in Singapore and plan to market it across the Asia-Pacific region this year,” said Mr. Clarence Johnson, director of Somnetics Global Pte Ltd. “We developed the entire Tran-

scend system to fit the users’ active lifestyles by listening to patients and incorporating the options that they want. Through the use of in-novative technology, we aim to change the way CPAP therapy is being delivered.”

The device works by delivering positive air pressure – through a tube and a mask – to prevent the airway from collapsing during sleep. Not only does it measure the apnea- hyponea index (AHI) or the number of pauses in breathing for every hour of sleep, it can also detect leaks.

Mr. Strong Huang, 37, was diagnosed as having OSA 2 years ago. Tests revealed that he was waking up an average of 44 times an hour and his blood oxygen level was low at 79 per-cent. Because of this, he was instructed to wear the CPAP device at night. However, his job requires him to travel a lot, and he has found the compactness of the new device to be more convenient for this reason.

“[Transcend] is small and quiet and the adjusted air pressure is just right for me. I can even use it on the plane. I’ve found that it reduces my snoring as well,” he said.

Reg iona l1-15 June 201223

Gene variant linked to poorer cancer treatment outcomes in Asian patientsRadha Chitale

Singaporean researchers have identified a gene variant specific to East Asian popula-tions that increases the risk of resistance to

standard therapy among patients with leukemia or lung cancer.

Targeted therapy to counteract the effect of the hereditary genetic mutation of the BIM gene in these patients could improve survival and let doc-tors avoid ineffective therapies and develop strate-gies to overcome or even prevent resistance in the future.

The BIM protein is necessary for tyrosine kinase inhibitors (TKIs) to induce apoptosis in cancer cells. The gene variant produces a faulty protein that leads to resistance to TKI therapy among patients with chronic myeloid leukemia (CML) and epider-mal growth factor receptor-mutated non-small-cell lung cancer (EGFR NSCLC).

“This is a normal variant of a gene that’s found in healthy populations, [at a rate of about 15 per-cent],” said Dr. Ong Sin Tiong, of the Cancer and Stem Cell Biology Signature Research Programme at Duke-NUS, Singapore, and the division of medi-cal oncology in the department of medicine at Duke University Medical Center, Durham, North Carolina, US. “However, if you are one of these in-dividuals with a variant of the gene and you were unlucky enough to also get CML, then you had a roughly three-fold increase of having an inferior or suboptimal response to your target therapy com-pared to those without this variant.”

He added that patients with TKI-treated EGFR NSCLC with a mutated BIM gene variant are more likely to experience disease progression faster than patients without it.

“This is a significant clinical difference,” he said.

About 80 percent of TKI-treated cancer patients respond to therapy while about 20 percent are re-sistant. Ong and his colleagues suspected BIM variants might account for TKI resistance in some cases.

Studies have shown that BH3-mimetics, which mimic the activity of the BIM pro-tein, can overcome BIM gene variant-relat-ed resistance and improve patient response to TKIs.

Ong and colleagues tested three Singaporean ethnic groups and found mutated BIM gene vari-ants to be present in 12.3 percent of Chinese, 6.8 percent of Malays and 0.5 percent of Indians. [Na-ture Medicine 2012 DOI:10.1038/nm.2713]

The presence of the BIM variant increased the risk of TKI resistance among CML patients by a factor of 2.94. EGFR NSCLC patients were likely to experience disease progression after 6 months on standard TKI therapy compared with 12 months among lung cancer patients without the mutation.

Testing for BIM variants could help clinicians identify who might benefit from BH3-mimetics as well as who would not respond to other potential-ly toxic treatments such as chemotherapy.

About 14,000 patients diagnosed each year with cancer carry mutant BIM gene variants, 35 of whom are in Singapore.

The researchers plan to develop and commer-cialize a test for the BIM gene variant, although it is unlikely that BIM variant testing would occur until after patients demonstrated resistance to TKIs. In addition, BH3-mimetics are not approved for use outside of clinical trials.

Clinically, determining the efficacy of BH3-mimetics plus TKIs among patients with BIM gene variants is the next step.

Reg iona l1-15 June 201224

Elvira Manzano

Breast cancer patients can experience chemotherapy-induced cognitive problems (‘chemobrain’), which may

significantly affect their lives, according to a new study.

The Singapore study, the first to examine the impact and pscychosocial effects of chemo-brain in Asian patients, has shown that breast cancer patients suffered difficulties in decision making and learning new tasks, memory loss, and speech and language problems after com-pleting chemotherapy.

That limited their capabilities at work and performance at home. [Ann Oncol 2012. DOI:10.1093/annonc/mds029]

Participants enrolled in the study were pre-dominantly Chinese, but others included Indi-ans, Malays, Filipinos and Papua-New Guin-eans.

Many of the study participants said they were embarrassed and scared at work as they realized they were unable to perform as well as before. Married participants expressed frustra-tion that they were unable to fulfill their duties as mothers and wives.

Chemobrain was unfamiliar to most partici-pants. Many thought of it as metastasis of the cancer to the brain or a risk factor for dementia.

They claimed they were not warned by oncologists as to the potential risk of cogni-tive problems associated with chemotherapy. Hence, participants attributed their mental lapses to fatigue, anxiety and mood changes.

They said they were overwhelmed by the

physical side effects of chemotherapy, such as numbness and vomiting, and that they were oblivious to the cognitive changes.

“It is alarming that the concept of this phe-nomenon is unfamiliar to most Asian cancer patients yet cognitive changes have signifi-cantly impacted their family and working lives,” said lead study author Dr. Alexandre Chan, associate professor in the department of pharmacy, National University of Singapore.

While family members had provided them good psychosocial support during cognitive decline, much of the negative impact on the family originated from their own expectations of themselves, as they were unable to fulfill their duties as mothers and wives. Nonethe-less, most of the participants are still receptive to chemotherapy despite knowledge of poten-tial cognitive effects.

To cope with cognitive impairment, many of the patients turned to mind stimulation activities such as mah jong and qi gong. Oth-ers used complementary alternative medicine such as walnut and ginkgo extracts to regulate their moods and reduce fatigue.

The researchers said the challenge lies in providing support measures that address not just the physical symptoms but the cognitive and psychosocial aspects of patients as well.

“A culturally relevant approach should be adopted to evaluate and manage perceived cognitive changes in these patients,” the au-thors said. “Well-designed epidemiological studies are needed to quantify the preva-lence, severity and impact of this problem in Asia.”

Study uncovers cognitive side effects of chemo

Reg iona l1-15 June 201225

Rajesh Kumar

Lowering the HbA1c cutoff for prediabe-tes from the current 6.4 percent to 5.7 percent will increase the health benefits

of preventive interventions, a US study has demonstrated.

While there is almost unanimous agreement that interventions should begin much before a patient achieves an HbA1c reading of 6.5 per-cent, the current diagnostic cutoff for diabetes, there is little consensus on what is the ideal cutoff point.

“This [latest research] is the first study to examine the population-level impact and cost effectiveness of using alternative HbA1c cutoffs to determine eligibility for type-2 diabetes pre-ventive interventions,” said lead investigator Dr. Xiaohui Zhuo from the division of diabetes translation at the US CDC.

The research team used a simulation model to examine the cost effectiveness associated with each progressive 0.1 percent decrease in the HbA1c cutoff from 6.4 percent to 5.5 percent.

The simulation used the data of non-di-abetic American adults from the National Health and Nutritional Examination Sur-vey. [Am J Prev Med 2012; DOI: 10.1016/j.amepre.2012.01.003]

People identified as having prediabetes were assumed to receive preventive inter-vention. The study looked at two different interventions: a high-cost resource-intensive approach that would cost on average almost US$1,000 per year, and a low-cost interven-tion with an annual cost of US$300 per year.

Researchers measured the cost per each quality-adjusted life year (QALY), a measure of the quality and quantity of life generated by a medical intervention, at each HbA1c cut-off for both interventions.

They found that cutoffs of 5.7 percent and above were cost effective, based on the con-ventional US$50,000/QALY cost-effective-ness benchmark. The results also suggested that the optimal cutoff may be lower if the cost of preventive interventions could be lowered without compromising effectiveness.

Dr. Cho Li Wei, consultant in endocrinol-ogy at Changi General Hospital in Singapore, however, said the recommendation may not be relevant for Asians.

It is based on population characteris-tics and health profiles of the study partici-pants, which might not be representative of our population, said Cho, adding that Asian physicians will need to interpret the findings with care.

Lower HbA1c cutoff proposed for prediabetes

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

MT Gyno + Circarol.eps 1 3/5/12 2:05 PM

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

MT Gyno + Circarol.eps 1 3/5/12 2:05 PM

Reg iona l1-15 June 201227

Rajesh Kumar

Modern approaches, including targeted therapies and aggressive surgical in-terventions, are now making it pos-

sible to extend the survival of patients with ad-vanced stage colorectal cancer patients by many years, even potentially achieving cure in 15 percent of such patients, according to Dr. Kong Hwai Loong, medical oncologist at the Mount Elizabeth Medical Center, and Dr. Tan Yew Oo, medical oncology and hematology consultant at Gleneagles Cancer Centre, Singapore.

Kong and Tan were speaking at a media roundtable in March to commemorate a Colorec-tal Cancer Awareness Month in Singapore.

Colorectal cancer has overtaken lung cancer in the last 5 years to become the most frequently occurring cancer among Singapore males (4,456 males were diagnosed between 2006 and 2010) and has remained the most frequently occurring cancer after breast cancer for females (3,750 fe-males were diagnosed during the same period). About 1,500 new cases are now being added to the tally every year, about half of them present-ing to their doctors when the cancer has already reached stage III or IV.

While surgical resection of tumors, chemo-therapy and limited use of radiotherapy are the usual treatment approaches, targeted therapies are now proving to be extremely useful in tu-mors with certain characteristics, said Kong.

Targeted therapy allows physicians to define a tumor’s molecular profile and deliver tailored treatments, thereby reducing the risk of dam-age to healthy cells and unnecessary side effects from treatments that may not work, said Kong.

KRAS genes found in colorectal tumors either have a ‘normal’ non-mutated protein known as

KRAS ‘wild-type’ (which appears in 60 percent of colorectal cancer patients) or abnormal KRAS protein known as KRAS ‘mutant’ (in the remain-ing 40 percent). In those with KRAS ‘wild-type’ genes, the agent cetuximab targets the biomark-er and interferes with a tumor cell’s capacity to grow and divide. It has been shown to prolong overall survival and treatment response rates in both first- and second-line chemotherapy.

In Singapore, cetuximab is indicated for met-astatic colorectal cancer (mCRC), in combination with chemotherapy or as a single agent in pa-tients who have failed oxaliplatin- and irinote-can-based therapy and who are intolerant to iri-notecan. Bevacizumab (Avastin) is another drug for the same indication, which works by block-ing the formation of new blood vessels, thereby interfering with the tumor’s growth. It is indicat-ed in combination with fluoropyrimidine-based chemotherapy.

Many more such targeted therapies are cur-rently under development, Tan said.

In the past, patients suffering from stage-IV mCRC, in which the cancer had spread to other parts of the body, were considered to be incur-able, said Tan. Targeted therapies can now help reduce the size of the tumor in such patients, allowing surgeons to remove the affected areas and changing the cancer status from incurable to curable, he added.

Kong urged patients to contact their GP if they experience any symptoms such as blood in stool or change in bowel habits.

“While some people get diarrhea when they get nervous, nocturnal pain or diarrhea can never be normal,” he cautioned, while stressing that early detection is still the best bet in the fight against colorectal cancer.

Advanced colorectal cancer not necessarily a death sentence

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I n te rna t iona l1-15 June 201229

Pacifiers and sippy cups potential toddler hazardsMalvinderjit Kaur Dhillon

Pacifiers and sippy cups are handy in feeding and lulling a child, but improper use could pose a hazard to

infants, according to a US study. The study analyzed data from the National

Electronic Injury Surveillance System (NEISS) and found that an estimated 45,398 children under the age of 3 required emergency care af-ter suffering injuries sustained from seeming-ly innocuous bottles, pacifiers or sippy cups over the last 2 decades. [Pediatrics 2012;129; DOI: 10.1542/peds.2011-3348]

A large number of the estimated injuries occurred when the toddler fell (86.1 percent) in the home, usually while drinking from a baby bottle. This caused lacerations or con-tusions to the mouth or face, said Dr. Sarah Keim, of the Research Institute at Nationwide Children’s Hospital, Columbus, Ohio.

“Parents do a lot of things to baby proof their home and make sure children’s toys are safe, but often don’t give a second thought to these products,” said Keim.

The children were grouped according to gender and age, from less than 1 year, 1 year, and ages 2 to 3.

Analysis of data collected from a network of 100 hospitals showed that 66.4 percent of injuries occurred in children younger than 1 year because of falls while using a bottle

or a pacifier. Compared with older children, 1-year-olds were 7.62 times more likely to fall. Keim noted that at this age, children are just learning to walk and, hence, are unsteady on their feet and more prone to falls. Most injuries occurred among boys (61.2 percent) as they tend to be more active.

The most commonly injured regions were the mouth (71 percent) followed by the head, face and neck (19.6 percent).

Overall, most injuries involved a bottle (65.6 percent), followed by a pacifier (19.9 percent) and a cup with drinking spout lid (14.3 percent).

“With older children, one reason for falling could be due to not paying attention to where they are walking while drinking from a bottle or a sippy cup, which could be compared to adults being distracted by texting while walk-ing,” said Keim.

She advised parents to follow the guide-lines set by the American Academy of Pediat-rics (AAP) on transitioning from bottles and sippy cups to lidless drinking cups when the child is around 1-year-old.

She also recommended that parents encourage children to sit while they eat or drink, rather than walk around with a bottle or cup during the day and ‘grazing’ or eating small amounts of food all day. This will not only help reduce accidents, but also promote better eating habits.

‘‘ ... parents encourage children to sit while they eat or drink …

I n te rna t iona l1-15 June 201231

Study shows how smoking causes COPDDhenuka Ganesh

New light has been shed on how chronic obstructive pulmonary dis-ease (COPD) develops in association

with long-term smoking. “Our findings have important implications

for understanding the etiology of COPD and suggest that pharmaceuticals designed to re-duce leukocyte recruitment through the bron-chial circulation may be a potential therapy to treat COPD,” said the study authors, led by Dr. Ryan P. Davis of the University of California (UC) Davis School of Medicine, California, US.

Their research revealed that tobacco smoke exposure stimulates neutrophils to migrate

from the bronchial blood vessels, due to the production of adhesion molecules and che-mokines, and accumulate in the lung tissues.

Although neutrophils help repair tissues, excessive numbers of activated neutrophils can release enzymes that kill cells and accel-erate inflammation.

In this study, a highly reproducible animal model of COPD was used to show that the equivalent of approximately 10 years of one-pack-a-day smoking completely damaged the bronchial airways by accelerating inflamma-tion, obstructing airflow and reducing normal lung function. [PLoS One 2012;7:e33304. Epub 2012 Mar 21]

The researchers studied rats having a ge-netic defect that made them react to smoke exposure much like humans with smoking-

related diseases. The animals developed all the physiological and anatomical traits of COPD.

A ‘smoking machine’ was used to automat-ically load, light and puff on cigarettes, and the rats were exposed to amounts that a two-pack-a-day smoker would be exposed to for 6 hours a day, 3 days a week.

After 4 weeks, their physiological changes reflected those of a 10- to 20-year smoker with complications of wheeze and cough and re-duced respiratory function. After 12 weeks, they were reflective of a 30- to 40-year smok-er having severe limitations in breathing and COPD.

The UC Davis team is now testing whether

statin drugs may prevent COPD development in this model. “The model appears to be ideal for screening drugs to treat early COPD, but the ultimate test comes when a treatment is transitioned from the lab to COPD patients,” said the lead author, Dr. Benjamin Davis. “Our primary goal is to save lives.”

According to the WHO, COPD is the fourth leading cause of death worldwide. In India, around 15 million people suffer from COPD-this number is expected to increase.

Dr. Aloke Gopal Ghoshal, director of the National Allergy Asthma Bronchitis Institute, Kolkata, India, stressed the importance of COPD management and treatment. “[In India], people who are more exposed to biomass fuel and smoke are at a greater risk of having COPD … this number is around 578 million.” ß

‘‘ Our findings have important implications for understanding the etiology of COPD

I n te rna t iona l1-15 June 201232

Exercise delays muscle wasting due to aging, heart failureLeonard Yap

Muscle wasting as a consequence of aging and heart failure can be counteracted with exercise, accord-

ing to new research.Exercise can reduce muscle breakdown,

increase strength and reduce inflammation caused by aging and heart failure. “Many physicians and insurance companies still believe that cardiac rehabilitation does not really help in old age. This study clearly falsi-fies this belief,” said Dr. Stephan Gielen, lead co-author and deputy director of cardiology at the University Hospital, Martin Luther University of Halle, Germany.

The results of the research were published online in Circulation, a journal of the Ameri-can Heart Association. [2012 May 7. Epub ahead of print]

The researchers found that the benefits of exercise were similar for both heart failure patients and the aging cohort. There was less muscle wasting in both groups and their bod-ies were conditioned to handle more exercise. The researchers also found that the age of the patients did not make a difference in terms of benefiting from exercise.

Between 2005 and 2008, researchers re-cruited 60 heart failure patients and 60 healthy volunteers. Half of each group was 55 years or younger and the other half, 65 years and older, resulting in an average age differ-ence of 20 years between the groups. Half the participants in each age group were randomly

assigned to 4 weeks of supervised aerobic training or no exercise. Researchers took mus-cle biopsies of all participants before and after the intervention.

The biopsy results showed that levels of a muscle protein indicating muscle breakdown, known as MuRF1, were higher in partici-pants with heart failure than in their healthier counterparts. However, exercise reduced MuRF1 and muscle inflammation, measured by levels of a protein called TNF-alpha. They also found that the strength of participants’ leg muscles increased in the younger and old-er heart failure patients after the 4-week exer-cise regimen.

The findings offer a possible treatment for muscle breakdown and wasting associated with heart failure and may prove that exercise can be therapeutic, even in elderly heart fail-ure patients. The findings also suggest an avenue for drug development to slow muscle breakdown in heart failure patients.

“Exercise switches off the muscle-wasting pathways and switches on pathways involved in muscle growth, counteracting muscle loss and exercise intolerance in heart failure patients,” Gielen said.

“Over the last three decades, hospital admissions for heart failure have increased four-fold and will continue to do so, due chiefly to the aging of the population,” Gielen said. Estimates of healthcare costs vary, but run in the tens of billions of dollars per year in the US alone, the researchers said.

I n te rna t iona l1-15 June 201233

Combo treatment better for youths with T2DMLeonard Yap

A combination of metformin and rosi-glitazone is more effective in treating youths with recent-onset type 2 dia-

betes (T2DM) than metformin alone, a study funded by the US National Institutes of Health (NIH) has shown.

The Treatment Options for type 2 Diabe-tes in Adolescents and Youth (TODAY) study concluded that metformin plus rosiglitazone was more successful in youths with T2DM compared to metformin alone. In addition, the study found that adding an intensive lifestyle intervention to metformin provided no greater benefit than metformin therapy alone.

The TODAY study was the first major com-parative effectiveness trial for the treatment of T2DM in young people. It was funded by the NIH’s National Institute of Diabetes and Diges-tive and Kidney Diseases (NIDDK), and the re-sults will be published in the New England Jour-nal of Medicine.

“The results of this study tell us it might be good to start with a more aggressive drug treat-ment approach in youth with type 2 diabetes,” said Dr. Philip Zeitler, TODAY study chair and a pediatric endocrinologist at Children’s Hos-pital Colorado, Aurora. “We are learning that type 2 diabetes is a more aggressive disease in youth than in adults and progresses more rap-idly, which could be why metformin alone had a higher than expected failure rate.”

The TODAY study enrolled 699 youths aged 10 to 17 who had T2DM for less than 2 years and a body mass index (BMI) at the 85th percentile or greater. Participants were randomly assigned to

one of three treatment groups: metformin alone, metformin and rosiglitazone combined, and metformin plus intensive lifestyle changes aimed at helping participants lose weight and increase physical activity. This was done to gauge how well and for how long each of the three treat-ment approaches controlled blood glucose levels in the youths.

The study found that treatment with metformin alone was inadequate for maintain-ing acceptable, long-term blood glucose control in 51.7 percent of youths over an average follow up of 46 months. The failure rate was 38.6 per-cent in the metformin and rosiglitazone group, or 25.3 percent lower, than in the metformin group. In the metformin plus lifestyle group, the failure rate was 46.6 percent.

“Despite a rigorous lifestyle intervention, we were unable to achieve sustained life-style changes in these youth, though similar strategies have proven effective in adults,” said Dr. Barbara Linder, NIDDK senior advisor for childhood diabetes research. “TO-DAY investigators will look more closely at those youth who succeeded in losing weight to better understand how to achieve effective lifestyle change in this population.”

More aggressive treatment may improve glucose control in diabetic youths.

I n te rna t iona l1-15 June 201234

Stem cells more effective in preventing organ rejection compared to antibodiesRadha Chitale

Bone marrow-derived mesenchymal stem cells (MSCs) prevented organ re-jection better than antibody induction

therapy in patients with end-stage renal dis-ease who received new kidneys.

Antibody induction therapy is routine in organ transplant procedures to prevent the host from attacking and destroying the for-eign tissue, but it can be toxic due to the ef-fects of the calcineurin inhibitors (CNIs) used in conjunction with the antbodies, as well as leaving patients vulnerable to infection.

Patients with end-stage renal disease re-quire dialysis or a kidney transplant.

“[MSCs] inhibit T-cell proliferation, mono-cyte differentiation to dendritic cells, modu-late B-cell functions, and suppress natural kill-er cytotoxic effects,” said researchers from the Organ Transplant Institute at Fuzhou General Hospital and Xiamen University in China. “Thus, MSCs offer new therapeutic opportu-nities to prevent transplant rejection.”

The trial included 159 patients with end-stage-renal disease who had undergone a kidney transplant from a living-related donor. Treatments were administered at kidney reperfusion and at 2 weeks. [JAMA 2012;307:1169-77]

Patients were randomized to receive either autologous MSCs plus a standard dose of im-munosuppressive CNIs (n=53), MSC plus a low-dose of CNIs (n=52), or anti-IL-2 recep-tor antibody plus standard dose CNI (n=51; controls).

“We found that autologous MSC recipients had faster renal function recovery during the first month, displayed fewer adverse events, and had reduced opportunis-tic infections than controls,” the research-ers said. “Thus, autologous MSCs may replace anti-IL-2 receptor antibodies and may allow for using lower CNI maintenance doses without compromizing patient safety and graft outcome.”

Survival was similar between groups at 13-30 months but 21.6 percent of control patients showed acute organ rejection at 6 months compared with 7.5 percent (P=0.04) and 7.7 percent (P=0.046) of MSC-treated patients in the standard and low-dose CNI arms, respectively.

Creatinine tests showed that MSC-treated patients had improved renal function in the month following surgery compared to the control arm.

Patients maintained this outcome at a 1-year follow up, which the researchers noted was encouraging as renal allograft function is a good indicator of long-term outcomes.

A combined analysis during the 1-year follow up of both MSC-treated groups showed a significantly decreased risk of opportunistic infection compared to the antibody-treated group (P=0.02).

“Extended monitoring of study partici-pants will allow assessment of the long-term effects of autologous MSCs on renal allograft function, survival, and safety,” the researchers said.

I n te rna t iona l1-15 June 201235

Suspect heart failure in breathless patientsRajesh Kumar

Physicians should consider the presence of heart failure in patients with breath-lessness and fatigue, or with worsening

of these symptoms, irrespective of their smok-ing status or other comorbidities.

The advice comes following the results of a US study that showed a link between compro-mised lung function, as measured by forced expiratory volume 1 (FEV1) in spirometry, and increased risk of heart failure. The association between lower FEV1 and higher risk of heart failure was not altered by age, prior heart dis-ease, or cardiovascular risk factors including smoking. [Eur J Heart Fail 2012; DOI:10.1093/eurjhf/hfs016]

The study researchers analyzed information on standardized spirometry tests and other co-variates on 15,792 men and women enrolled in the Atherosclerosis Risk in Communities (ARIC) survey conducted from 1987 to 1989. Incident heart failure in the cohort was ascer-tained from hospital records and death certifi-cates up to 2005 in 13,660 eligible participants.

Over a follow-up of nearly 15 years, 1,369 (10 percent) participants developed new-onset heart failure. The age- and height-adjusted haz-ard ratios (HRs) for heart failure increased for reducing FEV1 for genders, race groups, and smoking status.

After multivariable adjustment for tradition-al cardiovascular risk factors and height, the HRs of heart failure comparing the lowest with the highest quartile of FEV1 were 3.91 (95% CI 2.40–6.35) for white women, 3.03 (95% CI 2.12–4.33) for white men, 2.11 (95% CI 1.33–3.34) for black women, and 2.23 (95% CI 1.37–3.59) for black men.

This associa-tion weakened but remained s t a t i s t i c a l l y s i g n i f i c a n t after additional adjustment for systemic markers of inflammation. A consistent and positive asso-ciation with HF was seen for self-reported diag-nosis of emphy-sema and chronic obstructive pulmonary disease (COPD), but not for asthma.

The results, interpreted in the context of ex-isting scientific evidence, support a temporal relationship between low lung capacity and development of heart failure, said lead author Dr. Sunil Agarwal from the University of North Carolina, Chapel Hill.

This risk may be stronger than that seen for common and modifiable risk factors such as diabetes or hypertension, said Agarwal ,while emphasizing public health implications of the findings.

“It will be important to determine whether interventions that sustain or improve FEV1 are associated with lower risk of heart failure,” he added.

When asked about the findings’ relevance for Asians, Agarwal said while the research doesn’t allow for extrapolations, there is no reason the findings couldn’t apply to Asians.

“An earlier study [N Engl J Med 2010; 362:217-27] including Asians didn’t find any differences

COPD is a common comor-bidity in patients with heart failure, and vice versa.

I n te rna t iona l1-15 June 201236

Amyloid markers may predict dementiaElvira Manzano

The ratio of two amyloid-beta (Aβ) pep-tides in the blood may be an effective biomarker for the preclinical diagnosis of

dementia and Alzheimer’s disease (AD).This was the key finding from a meta-anal-

ysis of 13 prospective studies conducted in the US involving an overall total of 10,303 adult subjects.

The analysis showed that those with a lower Aβ42 to Aβ40 ratio were at increased risk of de-mentia (summary risk ratio [RR] = 1.67, 95% CI 1.02 to 2.75, P=0.04) and AD (RR=1.60, 95% CI 1.04 to 2.46, P=0.03) across studies. [Arch Neurol 2012; DOI:10.1001/archneurol.2011.1841]

The researchers, led by Mr. Alain Koyoma, SM, from the department of psychiatry, Univer-sity of California, San Francisco, US, examined previously published studies on plasma beta-amyloid levels (Aβ40, Aβ40 or Aβ42:Aβ40 ratio) and found that plasma levels of Aβ42 and Aβ40 alone were not significantly associated with de-mentia or AD risk. On the contrary, Aβ42:Aβ40 ratios were significantly associated with both conditions.

“The existing research offers cautious sup-port of the hypothesis that lower levels of the

plasma Aβ42 to Aβ40 ratio reflect a process of selective deposition of Aβ42 in the brain as insoluble amyloid plaques, thus predictive of dementia development,” the authors said. “Overall, the literature indicates that plasma Aβ42:Aβ40 ratios predict AD and dementia.”

The authors added, however, that the signifi-cant heterogeneity found in the study under-lines the need for more research on plasma Aβ as a possible preclinical biomarker for AD.

Current guidelines support the use of the more invasive and expensive cerebro-spinal fluid (CSF) and neuro-imaging markers to iden-tify preclinical AD. By contrast, “blood-based biomarker is simple, affordable and non-in-vasive, all of which are important qualities for population-based screening tools,” they said.

Another advantage of a blood-based marker is that it could be obtained easily and routinely in the clinic or in the patient’s home.

AD is the most common form of dementia, accounting for almost 50 to 70 percent of all cases. It is the seventh leading cause of death in the US, costing an estimated US$172 billion an-nually. The WHO estimated that in 2005, 0.379 percent of people worldwide had dementia, and that the prevalence would increase to 0.441 percent in 2015 and to 0.556 percent in 2030.

in association of emphysema and diastolic dysfunction in them, compared to other races,” he said.

Chronic obstructive pulmonary disease (COPD) is a common comorbidity in pa-tients with heart failure, and vice versa.

It is not yet confirmed that screening for COPD will reduce the risk of heart failure, or that managing COPD in heart failure pa-tients will improve outcomes, said senior

investigator Dr. Gerardo Heiss.“However, our results should add to the

growing awareness among practitioners that patients with COPD do have a higher risk of heart failure, and that shortness of breath or impaired vigor should not be ascribed prima facie to COPD without careful consideration of the presence of heart failure,” said Heiss.

I n te rna t iona l1-15 June 201237

Dopamine’s role - Gung-ho fighter or super-slacker?Leonard Yap

Are you an over-enthusiastic worker bee or a lounging sloth? The brain chemical dopamine is being impli-

cated as a marker for an individual’s motiva-tion to work, a new US study shows.

A new brain imaging study performed by Vanderbilt University’s Psychiatric Neuro-imaging Program and Vanderbilt Addiction Center in Nashville, has unveiled that an in-dividual’s willingness to work hard to earn money may be influenced by the amount of dopamine in three specific areas of the brain.

The study, published in the Journal of Neu-roscience, was performed by Vanderbilt sci-entists, including post-doctoral student Mi-chael Treadway and Professor David Zald. [2012;32(18):6170-6]

The researchers used positron emission tomography (PET) scans to map the brain of so-called ‘go-getters’, who were willing to work hard for rewards, and found higher re-lease of the neurotransmitter dopamine in ar-eas of the brain known to play an important role in reward and motivation – the striatum and ventromedial prefrontal cortex. On the other hand, ‘slackers’, who were less willing to work hard for reward, had high dopamine levels in another area of the brain associated with emotion and risk perception – the ante-rior insula.

The role of dopamine in the anterior insula was a complete surprise to the researchers. The finding was unexpected because has been

suggested that more dopamine in the insula is associated with a lower desire to work, even when it means earning less money.

As dopamine was found to have oppos-ing effects in different parts of the brain, this complicates the picture on the use of psycho-tropic medications that affect dopamine lev-els in the treatment of attention-deficit disor-der (ADHD), depression and schizophrenia because it calls into question the assumption that dopaminergic drugs have the same effect throughout the brain.

“Past studies in rats have shown that do-pamine is crucial for reward motivation,” said Treadway, “but this study provides new information about how dopamine deter-mines individual differences in the behavior of human reward-seekers.”

In addition to shedding new light on the workings of the brain, the research could have important implications for the treatment of attention-deficit disorder, depression, schizo-phrenia and other forms of mental illness characterized by decreased motivation.

The research was designed to search for objective measures for depression and other psychological disorders where motivation is reduced.

“Right now our diagnoses for these disor-ders is often fuzzy and based on subjective self-report of symptoms,” said Zald. “Imag-ine how valuable it would be if we had an objective test that could tell whether a patient was suffering from a deficit or abnormality in an underlying neural system.”

I n te rna t iona l1-15 June 201238

Stem cell shield against chemo’s toxic effectsLeonard Yap

It is now possible to use patients’ own blood stem cells to shield their bone mar-row against the toxic effects of chemother-

apy, a study shows.Scientists at the Fred Hutchinson Cancer

Research Center in Seattle, Washington, US, have found a novel way of transplanting a glioblastoma patient’s genetically modified blood stem cells as a shield to protect the bone marrow against chemotherapy toxicity.

Gene therapy using mutant methylguanine methyltransferase (P140K) gene-modified he-matopoietic stem and progenitor cells were used to circumvent the problem of toxic effects of chemotherapy on hematopoietic cells. The result of this ongoing study is published in Science Translational Medicine. [2012;4:133ra57]

The three patients in this study survived an average of 22 months after receiving trans-plants of their own circulating blood stem cells. One patient remained alive 34 months after treatment. Median survival for patients with glioblastoma without a transplant is just over a year.

“Glioblastoma remains one of the most devastating cancers with a median survival of

only 12 to 15 months for most patients,” said Dr. Maciej Mrugala, the lead neuro-oncologist for this study.

“We found that patients were able to toler-ate the chemotherapy better and without neg-ative side effects after transplantation of the gene-modified stem cells than patients in pre-vious studies who received the same type of chemotherapy without a transplant of gene-modified stem cells,” said Kiem.

Kiem, a member of the Clinical Research Division at the Hutchinson Center, said the toxicity of chemotherapy used in treating cancers like gliobastoma to the surrounding organs, particularly the bone marrow, has been the main barrier to its effective use. Side effects include decreased blood cell counts and increased susceptibility to infections. Dis-continuing or delaying treatment or reducing chemotherapy dosage is often practiced, but it often results in poorer response to treatment.

“This therapy is analogous to firing at both tumor cells and bone marrow cells, but giving the bone marrow cells protective shields while the tumor cells are unshield-ed,” said Dr. Jennifer Adair, who shared first authorship of the study with Dr. Brian Beard, both members of Kiem’s lab.

I n te rna t iona l1-15 June 201239

Induced labor not necessarily related to more C-sections, reduces perinatal deathsPank Jit Sin

The induction of labor in mothers be-yond 37 weeks of pregnancy does not lead to an increase in Cesarean section

rates, a study has concluded. On the contrary, labor induction in this

group can lead to a reduction in perinatal mortality (defined as death before, during or shortly after delivery) rates.

The findings were reported in a study published on 10 May in bmj.com. Using data from Scottish birth and death records, inves-tigators analyzed information on over 1.2 million women with single pregnancies who delivered after 37 weeks of pregnancy between 1981 and 2007. The outcomes were then adjusted for factors such as age at delivery, prior delivery and birth weight among others.

It was found that elective induction carried out on mothers pregnant for 37 to 41 weeks resulted in lower death rates compared with that for expectant management.

This was achieved without an increase in the need for Cesarean sections. At 40 weeks of gestation, the mortality rate was 0.08 percent (37 in 44,764 births) in the induction group, while the figure was much higher at 0.18 per-cent (627 in 350,643 births) in the expectant management group.

Elective induction was, however, associ-ated with an increase in admission rates to special care baby units (8 percent) compared

with expectant management (7.3 percent). This translates to one newborn death pre-

vented for every 1,040 women having elec-tive inducted labor at 40 weeks. This would also mean an increase in seven more admis-sions to a special care baby unit.

The authors concluded that elective induction of labor at term has the potential to reduce perinatal mortality in developed countries without increasing the risk of operative delivery, but cautioned that other unmeasured factors may have contributed to the study results.

Ed- Also it is notable that research method-ology of population based retrospective cohort analysis, has significant limitations in terms of its reliability and risk of bias when compared to the ‘gold standard’ of high quality randomised controlled trials.

Induction of labor could spell better survival for mothers and infants if done properly.

I n te rna t iona l1-15 June 201240

‘Social jetlag’ linked to obesity epidemicPank Jit Sin

The mismatch between the body’s internal clock and packed daily schedules contributes to more than

sleep loss: it could also lead to obesity, a new study has revealed.

According to the online version of Current Biology, published on May 10, ‘social jetlag’ is a big contributor to the growing rate of obesity. This was the finding of a large-scale epidemiological study carried out by German researchers.

Til Roenneberg, a professor in the Institute of Medical Psychology, University of Munich, said each hour of social jetlag increases the risk of being overweight or obese by 33 per-cent.

Roenneberg explained that each person has a biological clock that is entrained by day (light) and night (dark) to provide the optimal amount of time for sleeping and waking. People in modern societies tend to ignore their body clocks “due to the increasing discrepancy between what the body clock tells us and what the boss tells us.”

Roenneberg’s team is currently compiling a vast database on human sleeping and waking patterns which will be used to create a world

sleep pattern map. After 10 years of data collection, the team has collected information that includes participants’ height, weight and sleep patterns.

Analyses of the data showed an increasing discrepancy between the daily timing of the physiological clock and the social clock. This condition leads to chronic sleep deprivation. Additionally, people are also more likely to smoke, and drink more alcohol and caffeine.

There is a correlation between those who are most severely socially jetlagged and the likeli-hood of being obese. The researchers surmise that our modern way of living, which goes against the physiological clock, may be a factor in the obesity epidemic.

The discrepancy between what your body needs and what you want may be contributing to the increase in waist girth.

I n P rac t i ce1-15 June 201241

Dr. Eugene WongConsultant Orthopedic & Spine SurgeonAdjunct Assistant ProfessorPerdana University Graduate School of MedicineSerdang, Selangor

Thoracic pain: A review

IntroductionThoracic pain is defined as pain experienced in the area bounded superiorly by a trans-verse line through the tips of the spinous process of T1, inferiorly by that of T12, and laterally along the lateral margins of the erec-tor muscle. The diagnosis of the source of pain in this region can be difficult. Thoracic pain may have a better natural history than neck or lower back pain, with fewer incidences of recurrent symptoms.

EtiologyThe causes of thoracic pain can be classified as in Table 1. The source of pain could be from the joints, bones, paravertebral muscles and liga-ments. The joints involved include the costo-transverse, costovertebral and zygapophyseal joints. The majority of causes is mechanical in origin and is only rarely due to red-flag condi-tions. A differential diagnosis of thoracic pain is given in Table 2. Patients above 60 years are at risk of spontaneous osteoporotic fractures of the thoracic spine. A triggering event for osteoporotic fractures is often not present and it can be spontaneous in up to 46 percent of patients.

Clinical presentationThoracic radiculopathy is characterized by ra-diating pain in a localized area of an intercos-tal nerve. The two commonest causes include

thoracic disc disease and diabetes mellitus. Thoracic disc protrusion is common in asymp-tomatic individuals, but when it does become symptomatic, it is responsible for neurologi-cal features. Physical examination is not a reliable way to diagnose thoracic radiculopathy. There may be localized spinal and paraspinal tender-ness, and sensory changes in a dermatomal pattern. Diabetic thoracic radiculopathy usu-ally occurs in older, non-insulin-dependent diabetic men and runs a self-limiting course of approximately 6 to 18 months before symp-toms resolve.The thoracic spinal cord can be compressed by a large central disc or a calcified disc. Myelopathy would present as bladder incon-tinence, a wide-based ataxic gait and upper motor neuron signs such as positive Babinski sign, hyper-reflexia and ankle clonus.

Table 1: Classification of thoracic pain.

A) Painful conditions of the thoracic spine1) Serious conditions Infection Fracture Neoplastic disorders

2) Mechanical conditions Discogenic pain Facet joint pain

B) Conditions referring pain to the thoracic spine

1) Somatic conditions Disorders of cervical zygapophyseal joints,

muscles and discs.

2) Visceral conditions Myocardial ischemia Dissecting thoracic

aortic aneurysm Acute cholecystitis

Inflammatory disorders

Disc protrusion

Peptic ulcer Pancreatitis

Acute pyelonephritis Renal colic

I n P rac t i ce1-15 June 201242

FIG 1 FIG 6FIG 2 FIG 7FIG 3 FIG 4 FIG 8FIG 5 FIG 9

Table 2: Differential diagnosis of thoracic pain.

A) Non-spinal causes1) Musculoskeletal Postthoracotomy

syndrome Polymyalgia

rheumatica Fibromyalgia

2) Intrathoracic Cardiovascular Pulmonary

3) Intra-abdominal Mediastinal

Hepatobiliary Mediastinal Retroperitoneal

B) Spinal causes1) Degenerative Degenerative disc

disease Facet syndrome

2) Neoplastic Primary

3) Infectious

4) Metabolic Osteoporosis

5) Neurogenic Disc herniation Spinal cord

neoplasm

6) Deformity Scoliosis Kyphosis

Rib fractures Intercostal neuralgia

Mediastinal

Mediastinal Gastrointestinal

Metastatic

Osteomalacia

Inflammatory (e.g., herpes zoster)

Arteriovenous malformation

Trauma

Table 3: Features of red-flag conditions.

A) Fracture History of minor trauma (if patient is>50),

history of osteoporosis and taking corticosteroids.

History of major trauma

B) Infection Fever Night sweats Risk factors forinfection (immunosuppression,

penetratingwound). C) Tumor

Past history of malignancy

Age >50 Unexplained

weight loss Failure to improve

with treatment

D) Other conditions Chest pain Shortness of

breath, cough

Night pain

Pain at multiple sites Pain at rest

Abdominal pain

Thoracic disc

prolapse

Scheurmann’s

disease

Thoracic

epidural

abscess

Tuberculous

spondylitis

Thoracic

compression

fracture

Intradural

intramedullary

tumour

Thoracic

metastasis

Thoracic

kyphosis

Thoracic

stenosis in

achondroplasia

Spondylosis

Spinal stenosis

Thoracic spinal stenosis is the narrowing of the anteroposterior diameter of the thoracic spinal canal to less than 10 mm. Stenosis may be due to Scheuermann’s disease, epidural li-pomatosis and achondroplasia. Paravertebral pain that is aggravated by prolonged stand-ing, hyper-extension or rotation is suspicious of facet joint pain.History serves to differentiate sources of acute thoracic spinal pain to identify features of

I n P rac t i ce1-15 June 201243

potentially serious conditions. (Table 3) It car-ries little diagnostic weight. The reliability of palpation for tenderness of the thoracic spine is good, but its validity is unknown. Precise diagnosis relies on a strong clinical suspicion that is confirmed with appropriate diagnostic imaging. Magnetic resonance imaging (MRI) and computed tomography (CT) scan will show a large number of asymptomatic herni-ated thoracic discs. These findings need to be evaluated to avoid over-treatment of asymp-tomatic patients with abnormalities on imag-ing studies. Imaging of conditions which can give rise to thoracic pain are given in Figures 1 to 9.

Treatment OptionsMost patients with symptomatic thoracic disc disease will respond favorably to non-opera-tive management. In patients with predomi-nantly axial pain without significant radicular symptoms, the treatment in the acute phase should consist of activity modification and NSAIDs. Transcutaneous electrical nerve stimulation can be used to ease pain. Physi-cal therapy is usually applied in the form of manual therapy. Hyper-extension exercises of the thoracic spine are beneficial.Interventional treatment can be considered when conservative treatment fails. Pulsed radio-frequency treatment of the dorsal root ganglion can be used for thoracic radicular pain. Patients who present with unremit-ting thoracic radicular pain and/or progres-sive myelopathy caused by a structural cause despite conservative treatments for 2 months may be candidates for surgical intervention. Surgery is indicated for a patient with an acute thoracic disc herniation with progres-sive neurological deficit (features of thoracic spinal cord myelopathy).

1-15 June 201244 Af te r Hours

One doctor tells of his evolving culinary creations at home in

addition to crafting healthy traditional meals for the whole

family. Rajesh Kumar reports.

Dr. Poh Beow Kiong is a d i e h a r d

foodie. His day job as a urology consultant at Singapore’s Changi General Hospital keeps him quite busy. But on occasional weekday evenings and the weekends, Poh takes on the role of a kitchen maestro, whipping up quick, healthy dinners for the family.

“Some find cooking to be a chore,” he says, “But I find it therapeutic. It relaxes me after a long day at work.”

Besides, the family doesn’t like to eat out. “Occasionally, when we do, it is on days when our kids go for swimming lessons. We buy takeouts rarely,” said Poh.

While he has not developed a signature style, Poh said his cooking has undergone a sort of evolution over the years.

“Ten years ago, we used to eat a lot of fried food and used more oil in our cooking. Now, we are more health conscious and tend to steam our fish, vegetables and even chicken, rather than fry them.”

While healthy eating is the norm, Poh occasionally indulges in fatty food and believes cer-tain traditional recipes shouldn’t be altered, no matter how calorie dense the dish may be.

1-15 June 201245 Af te r Hours

“Chinese fatty pork cooked in duck soya sauce, for example. That is an extremely greasy but sumptuous dish. And trying to cook it with anything other than fatty pork is pointless,” he said.

“Obviously, you don’t eat such food regu-larly and need to burn off the extra calories through vigorous exercise. Else, the coronary arteries will clog up,” cautioned Poh.

“But many special dishes, and the way they are cooked, are a part of our cultural heritage that needs preserving …You ask your mum how these are cooked, write down the recipes, add your tweaks over the years and pass them on to the next genera-tion. That should never be lost!”

Is there a favorite dish he likes more over oth-ers? “My mother’s home cooked popiah is the best,” Poh said excitedly. Like chilly crab, popiah is among Singapore’s iconic dishes and that is prepared by wrapping a choice of cooked fill-ings in paper thin crepe, usually bought ready made from the market.

Dried shrimps and cooked pork, vegetables, mushrooms, crab meat and other ingredients can be mixed with boiled radish to make differ-ent fillings. The crepe is used as it is and rolled

up like a sushi roll after dabbing it with sweet sauce, hot chilli paste and stuffing the fillings before cutting the rolls into pieces.

Poh’s culinary skills have endeared him to his family and the mother-in-law. He en-courages his fellow physicians to try their hand at cooking and offers to share the rec-ipe for a healthy snack, which anyone with negligible cooking skills can master:

Take a chunk of egg tofu. Pan fry it, drain the excess oil on kitchen paper and cut into pieces. Chop and fry some garlic to pleasant golden brown color, sprinkle on tofu pieces and, voila!

The natural sweetness of the egg tofu and light pungency of the fried garlic work so well together that you may not need a dipping sauce. Just make sure not to over-cook the garlic, or it will taste bitter.

The cooking process continues even after you turn off the heat. As the garlic turns light brown, turn the heat off and drain out the excess oil before it overcooks. It’s not easy to brown the egg tofu. Pat it dry with kitchen paper, drizzle oil on a really hot pan and leave it to sizzle on one side for several minutes before turning it over.

1-15 June 201246 Af te r Hours

ChengduLand of Tea ,

Tao & Pandas Chengdu epitomizes today’s China – modern, yet historical and quaint.

Leonard Yap writes.

Chengdu is truly a place of stark con-trasts and contradictions. At one end of the spectrum are large modern

buildings and tall elevated highways looming over the city; at the other, you have the old weathered historical buildings dating back centuries and narrow pedestrian walkways. You have Starbucks outlets at every corner and quaint little tea houses dotting the side-walks.

There is a big tea-drinking culture in Chengdu, with many types of green teas grown locally. People sip tea on the sidewalks, people-watching and whiling away the time. There is an unusual level of coziness among the people at the teahouses, which is in sharp contrast to the hustle and bustle around them.

The tea culture dates back to the Western Han period from 206 BC and 220 AD, when both the tea trade and tea culture were thriv-ing in Sichuan province, with Chengdu as the starting point of the Southern Silk Road.

About an hour’s drive (without traf-fic) and 70 km out of Chengdu lies Mount Qingcheng. Among the most important centers of Taoism in China, it is sit-uated on the outskirts of Dujiangyan City and connected to downtown Chengdu by a modern expressway.

1-15 June 201247 Af te r Hours

With its peak 1,260 m above sea level, Mount Qingcheng is cool and green all year round, and surrounded by hills and waterways. Laojun Temple and Qingcheng Celestial Hall top its peak and is made easily accessible via cable car. Cable cars glide up through the green forest, provid-ing a breathtaking view of the surrounding mountains. For the adventurous, the climb to the summit is a spirited trek sprinkled with spectacular views and little temples dotting the path.

Taoism is a fundamentally Chinese phi-losophy and religious tra-dition that emphasizes liv-ing in harmony with the Tao, which can be translat-ed as the ‘way’ or ‘path.’ Its sacred text, the Tao Te Ching, opens with this po-etic line, ‘The Tao that can be named is not the absolute Tao,’ pointing to a spiritu-al force that is ultimately beyond our grasp. Tao-ism emphasizes wu wei (action through inac-tion), simplicity, sponta-neity and harmony be-tween the individual and the cosmos.

No trip to Chengdu is com-plete without a visit to the Gi-ant Panda Research Base. It has a huge breeding and research base for giant and red pandas, and attracts scores of visitors from all over the world. Cover-ing an area of 106 hectares, the research base is filled with bam-

boo groves that mimic the animal’s native habitat. It is very entertaining to watch pan-das going through their daily routine, which includes eating bamboo, taking a nap and playing (for the young ones). One can only feel a hint of envy at the life of the panda, devoid of the complications of human life.

Chengdu is certainly a place of surprises and contrasts, where one can get away and yet not be too far away from the conve-niences of modern life.

Humor1-15 June 201248

“You're a very lucky man Harry, you could have broken your nose!”

“I have good news and bad news. The bad news is that the DNA tests showed that it was your blood they found at the crime scene.

The good news is your cholesterol is down to 120!”

“I'm sick of being sick Doctor. Is there an illness other than the one I have that I might

enjoy?”

“The place is empty. Everybody called in sick!”

“Enjoy your vacation. I'll tell you the bad news

when you get back!”

“I thought you told me to go on a diet just to be mean!”

“I've terrible news. You are not a hypochondriac!”

1-15 June 201249 Ca lendarMALAYSIAn EVEnTS

JuneRoyal College of Obstetricians and Gynaecologists (RCOG) 10th International Scientific Meeting 20125/6 to 8/6; KuchingInfo : Dr. Gunasegaran RajanTel : (03) 6201 3009Fax : (03) 6201 7009Email : ogsm@myjaring.netwww.rcog2012.com

4th National Early Childhood Intervention Conference7/6 to 9/6; SibuInfo : Dr. Toh Teck HockTel : (084) 217 912 Fax : (084) 213 902Emai : necic2012@gmail.comhttp://agapesibu.org/necic2012/

Computational Chemistry Techniques in Drug Design12/6 to 14/6; Kuala LumpurInfo : SecretariatEmail : siaolin.liong@imu.edu.mywww.imu.edu.my

4th Parenteral & Enteral Nutrition Society of Malaysia (PENSMA) 201214/6 to 16/6; PenangInfo : SecretariatTel : (03) 4023 4700Fax : (03) 4023 8100Email : secretariat@pensma.orgwww.PENSMA.org

42nd Malaysian Orthopaedic Association Annual General Meeting & Annual Scientific Meeting14/6 to 18/6; KuantanInfo : SecretariatTel : (016) 203 6018Fax : (03) 6207 6795Email : moa2012@bloomcomm.comwww.moa-home.com

Workshop on Preceptorship for Healthcare Professionals18/6 to 19/6; Kuala LumpurInfo : SecretariatEmail : siaolin.liong@imu.edu.mywww.imu.edu.my

5th IMU/AFPM Family Medicine Clinical Skills Course23/6 to 24/6; Kuala LumpurInfo : SecretariatEmail : siaolin.liong@imu.edu.mywww.imu.edu.my

Diabetes & the Heart Seminar/ Grand Rounds23/6 to 24/6, Kuala LumpurInfo : National Diabetes Institute, NADITel : (03) 7876 1676 / 7876 1677Fax : (03) 7876 1679Email : enquiry@nadidiabetes.com.mywww.diabetesmalaysia.com.my

7th Biennial Conference on Cardiopulmonary Bypass28/6 to 1/7; KuchingInfo : SecretariatTel : (03) 9207 9617Fax : (03) 9207 9662Email : cpb72012@yahoo.comwww.7cpb2012.com

Annual Scientific Meeting of the Malaysian Society of Gastroenterology and Hepatology (GUT 2012) 29/6 to 1/7; MalaccaInfo : SecretariatTel : (03) 4023 4700 / 4025 4700Fax : (03) 4023 8100Email : secretariat@msgh.org.mywww.msgh.org.my

1-15 June 201250 Ca lendar

July

Using Person-centered Expressive Arts Therapy for Emotional Healing5/7 to 6/7; Kuala LumpurInfo : SecretariatEmail : siaolin.liong@imu.edu.mywww.imu.edu.my

Malaysian Thoracic Society Annual Congress 20126/7 to 8/7; KuchingTel : (03) 4023 4700 / 4025 4700Fax : (03) 4023 8100Email : secretariat@mts.org.mywww.mts.org.my

1st Asia Pacific Conference on Clinical Epidemiology & Evidence Based Medicine 6/7 to 8/7; Kuala LumpurInfo : Ms. Devi PeramalahTel : (03) 7967 3793/ 7967 3797Fax : (03) 7967 4975 Email : apceebm1@ummc.edu.mywww.apceebm.um.edu.my

13th MSR-SSR Workshop in Rheumatology 20126/7 to 8/7; PenangEmail : secretariat@msr.mywww.msr.org.my

Workshop on Communicating Science for the Medical, Health and Life Sciences9/7; Kuala LumpurInfo : SecretariatEmail : siaolin.liong@imu.edu.mywww.imu.edu.my

Malaysian Dietitians’ Association Annual Scientific Meeting and 18th Annual General Meeting9/7 to 10/7; SelangorInfo : SecretariatTel : (016) 206 9610Fax : (03) 6207 6795Email : conference@dietitians.org.mywww.dietitians.org.my

46th Malaysia-Singapore Congress of Medicine12/7 to 14/7; Kuala LumpurInfo : SecretariatTel : (03) 4023 4700 / 4025 4700Fax : (03) 4023 8100Email : acadmed@po.jaring.my

16th Malaysia Family Medicine Scientific Conference13/7 to 15/7; MalaccaInfo : Dr. Junaidah Abd RahmanTel : (06) 3842533www.conference2012.fms-malaysia.org

APHM International Healthcare Conference & Exhibition 17/7 to 19/7; Kuala LumpurInfo : Ms. MajminTel : (03) 4251 7032Fax : (03) 4251 7031Email : majmin8@gmail.comwww.aphmconferences.org

August

Workshop on Writing Research Proposals in the Health and Life Sciences6/8; Kuala LumpurEmail : siaolin.liong@imu.edu.mywww.imu.edu.my

1-15 June 201251 Ca lendarInTERnATIOnAL EVEnTS

June2012 Annual Meeting of American Society of Clinical Oncology (ASCO) 1/6 to 5/6; Chicago, Illinois, USInfo : Secretariat Email : ascoregistration@jspargo.comhttp://chicago2012.asco.org/

10th International Conference of the Asian Clinical Oncology Society13/6 to 15/6; Seoul, South KoreaInfo : SecretariatEmail : office@acos2012.org / scientific@acos2012.orgwww.acos2012.org

15th International Congress on Infectious Diseases (ICID) 13/6 to 16/6; Bangkok, ThailandInfo : SecretariatEmail : info@isid.orgwww.isid.org/icid/

6th International Nasopharyngeal Carcinoma Symposium20/6 to 22/6; Istanbul, TurkeyInfo : SecretariatEmail : npc2013@eaorganizasyon.com.trwww.npc2013.org

August

2012 2nd International Conference on Environmental, Biomedical and Biotechnology ICEBB 20124/8 to 5/8; DubaiInfo : SecretariatEmail : icebb@cbees.orgwww.icebb.org

European Society of Cardiology Congress 25/8 to 29/8; Munich, Germanyhttp://www.escardio.org/congresses/esc- 2012/Pages/welcome.aspx

October15th Biennial Meeting of the European Society for Immunodeficiencies (ESID 2012)3/10 to 6/10; Florence, ItalyInfo : SecretariatEmail : esid@kenes.comwww.kenes.com/esid

23rd Great Wall International Congress of Cardiology (GW-ICC) & Asia Pacific Heart Congress 2012 11/10 to 14/10; Beijing, ChinaInfo : SecretariatEmail : secretariat@heartcongress.orgwww.heartcongress.org

42nd Annual Meeting of the International Continence Society15/10 to 19/10; Beijing, ChinaInfo : SecretariatEmail : ics@kenes.comwww.kenes.com/ics

november8th International Symposium on Respiratory Diseases & ATS in China Forum 20129/11 to 11/11; Shanghai,ChinaInfo : SecretariatEmail : secretariat@isrd.orgwww.isrd.org

DecemberWorld Allergy Organization International Scientific Conference (WISC 2012)6/12 to 9/12; Hyderabad, IndiaInfo : SecretariatEmail : WISC@worldallergy.orgwww.worldallergy.org/WISC2012

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Vietnam : Nguyen Thi Lan Huong, Nguyen Thi My DungTel: (848) 3829 7923 Email: enquiry.vn@ubmmedica.com

Europe/USA : Kristina Lo-KurtzTel: (852) 2116 4352 Email: enquiry.hk@ubmmedica.com, maria.kaiser@ubmmedica.com

Medical Tribune is published 12 times a year (23 times in Malaysia) by UBM Medica, a division of United Business Media. Medical Tribune is on controlled circulation publication to medical practitioners in Asia. It is also available on subscription to members of allied professions. The price per annum is US$48 (surface mail) and US$60 (overseas airmail); back issues at US$5 per copy. Editorial matter published herein has been prepared by professional editorial staff. Views expressed are not necessarily those of UBM Medica. Although great effort has been made in compiling and check-ing the information given in this publication to ensure that it is accurate, the authors, the publisher and their servants or agents shall not be responsible or in any way liable for the continued currency of the information or for any errors, omissions or inaccuracies in this publication whether arising from negligence or otherwise howsoever, or for any consequences arising there-from. The inclusion or exclusion of any product does not mean that the publisher advocates or rejects its use either generally or in any particular field or fields. The information contained within should not be relied upon solely for final treatment decisions.

© 2012 UBM Medica. All rights reserved. No part of this publication may be reproduced in any language, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, pho-tocopying, recording or otherwise), without the written consent of the copy-right owner. Permission to reprint must be obtained from the publisher. Ad-vertisements are subject to editorial acceptance and have no influence on editorial content or presentation. UBM Medica does not guarantee, directly or indirectly, the quality or efficacy of any product or service described in the advertisements or other material which is commercial in nature.

Philippine edition: Entered as second class mail at the Makati Central Post Of-fice under Permit No. PS-326-01 NCR, dated 9 Feb 2001. Printed by Fortune Printing International Ltd, 3rd Floor, Chung On Industrial Bldg, 28 Lee Chung Street, Chai Wan, Hong Kong.

ISSN 1608-5086

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 Universiti Kebangsaan Malaysia

Urology Prof. Dato’ Dr. Sahabudin Raja Mohamed Prince Court Medical Centre

Gastroenterology Prof. Dato’ Dr. Goh Khean Lee University Malaya Medical Centre

ENT Prof. Dato’ Dr. Balwant Singh Gendeh Hospital Universiti Kebangsaan Malaysia

Family Medicine Prof. Datin Dr. Chia Yook Chin University Malaya Medical Centre

Endocrinology Dr. Chan Siew Pheng Sime Darby Medical Centre

Respiratory Datuk Dr. Aziah Ahmad Mahayiddin Medicine Institute of Respiratory Medicine

Anesthesiology Prof. Dr. Ramani Vijayan University Malaya Medical Centre

Infectious Diseases Prof. Dr. Adeeba Kamarulzaman University Malaya Medical Centre

Psychiatry Prof. Dr. Mohamad Hussain Habil University Malaya Medical Centre

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) University Malaya Medical Centre

Orthopedic & Dr. Eugene Wong Spine Surgery iHEAL Medical Centre