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1-15 March 2012

MT Astra Zeneca Crestor_1_3 column.ai 1 1/5/12 11:21 AM

Elderly respond much better to H1N1 flu jabs

BRIEFSEnzyme replacement therapy for lysosomal storage diseases

MALAYSIA FOCUS

Bedwetting – the problem may be the bowel

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3 1-15 March 2012

Bedwetting – the problem may be the bowel Pank Jit Sin

Astudy carried out by researchers at the Wake Forest Baptist Medical Center,

North Carolina, US, has discovered that a large number of study subjects had exces-sive amounts of feces in the rectum despite having normal bowel habits. [Urology 2011 Dec 13, Epub ahead of print]

A total of 30 subjects, including chil-dren and adolescents aged between 5 and 15 years, were included in the study. The subjects had sought treatment for bed-wetting. After being treated with laxatives, 25 patients were cured of bedwetting in a span of 3 months.

According to study lead author Dr. Steve J. Hodges, assistant professor of urology at Wake Forest Baptist Medical Center, having too much stool in the rectum directly affects bladder capacity. He added that parents usually try many methods to cure bedwet-ting, including alarms and liquid restriction. However, in many children, such methods do not yield a response because constipa-tion is the culprit.

Hodges noted that the link between bed-wetting and excess stool in the rectum was identified as far back as 1986. Unfortunately, the finding did not lead to a change in treat-ment paradigm for bedwetting.

He alluded to the possibility of consti-pation being poorly defined, and not uni-formly understood by physicians and the general public.

In the study, all the children had excess stool in the rectum, which could interfere with normal bladder function, but only three described bowel habits that were

consistent with being constipated.

Poor understanding of constipationHodges said that the guidelines of the International Children’s Continence Society recommend asking children and their par-ents about the child’s bowel movements (whether it is irregular) and if the stool con-sistency is hard.

The questions will only identify peo-ple with functional constipation and miss those with an enlarged rectum, which interferes with bladder capacity. “The kind of constipation associated with bedwetting occurs when children put off going to the bathroom. This causes stool to back up and their bowels to be never fully emptied.” It is believed that treating this condition can lead to a cure for bedwetting.

The participants were treated with poly-ethylene glycol, which softens and causes the stool to retain water. Those who required further medication were given enemas or stimulant laxatives.

Waking up a kid in the middle of the night to go to the toilet may not be the best way to cure his bedwetting.

4 1-15 March 2012 ForumHypertension in Malaysia an ongoing struggle By Dr. Azani Md. Daud, President of the Malaysian Society of Hypertension (MSH), at the MSH’s 9th Annual Scientific Meeting, 10-12 February, Kuala Lumpur.

Hypertension remains one of the biggest problems that doctors face. Malaysia

is no different from any other country in the world, and hypertension remains the most important cardiovascular risk factor. Unfortunately, as our country becomes more affluent, we tend to follow a rather less healthy lifestyle, with the resultant explosion in the incidence of non-commu-nicable diseases.

Cardiovascular disease remains the number one killer in this country and we have not really made much headway in try-ing to bring it down. One of the challenges that we face is that despite the wealth of knowledge that we have and the burden of evidence that we have, the problem has always been, ‘How do we translate the knowledge that we have into useful and practical clinical practice that makes a dif-ference in bringing down hypertension?’

We are only diagnosing 40 percent of hypertension cases. Therefore, for every four that we diagnose with hypertension, there are six people walking outside totally unaware they have hypertension. We have only managed to achieve target control in 27 percent of those who are treated. We must, therefore, work harder to achieve better control and reduce the risk of car-diovascular disease in this country.

One of the initiatives of the MSH, in conjunction with the Ministry of Health and the Academy of Medicine Malaysia, was the introduction of the clinical prac-tice guidelines (CPG). They have been con-stantly revised and are now in their third

edition. The third edition of the CPG will undergo a revision, with a newer edition about to be launched soon.

Despite the introduction of the CPG, we find that many practices do not really con-form to the CPG. We have also introduced a quick reference guide to make it is easier for doctors to carry the guide in their pock-ets. We have also introduced a training module book which we are using to train all junior staff as well as private practition-ers so that they will be familiar with the CPG.

Last year, the MSH initiated a training program in three different parts of the country in recognition of the fact that doc-tors practising outside the Klang Valley have informed us that they do not get the opportunity to attend our meetings as fre-quently as they would like and, therefore, have neglected to continue in their profes-sional development.

What the MSH did last year and will

People are often not aware that hypertension is a risk factor for many cardiovascular diseases.

5 1-15 March 2012 Forumcontinue to do so this year, is to arrange regional teaching programs in different parts of the country using our training module book. The MSH has also awarded grants to encourage research. To institu-tions or anybody interested in research for hypertension, you can go to the MSH web-site, download the forms and apply for the grants. We have disbursed in the last year RM50,000 in grants to five different inves-tigators. The only thing we require is that the research is done locally and presented at our annual scientific meeting.

There are many factors that influence the control of hypertension. There are some countries in the region that have been more successful than others in bring-ing about good control. If you look at

Taiwan, for example, in the 1990s it intro-duced a national health insurance scheme. This has directly led to an increase in avail-ability of treatment by up to two- to three-fold and achieving target control by about three- to four-fold since the introduction of the national health initiative.

We in Malaysia have heard about the national health initiative for many years. We are all awaiting the details of this initiative. We would like to see how we can all play a part in making it successful as far as the treatment of hypertension is concerned, so that the treatment is more widely available and we are able to optimize treatments for our patients. We need to look at countries that have a success story to see if we can replicate that in our local setting.

MT Pharmaniaga Plecaz_1_3 column.ai 1 1/5/12 11:19 AM

6 1-15 March 2012 Medica l Br ie fsElderly respond much better to H1N1 flu jabs

Elderly people have a 10-fold higher anti-body response to the vaccine against

the 2009 swine flu human pandemic (H1N1pdm09) compared with younger cohorts, a study has found.

Researchers performed an analysis of antibody responses generated in 1,313 elderly (aged 66 to 83) and younger (18 to 45 or 46 to 65) adults, through serum samples obtained at baseline and 21 days post–H1N1pdm09 vaccination. [J Infect Dis 2011 DOI:10.1093/infdis/jir91]

Post-vaccination serum samples from the elderly subjects also showed substan-tially higher avidity than from younger subjects (>60 percent versus <30 percent resistance to 7 mol/L urea). Females under the age of 65 had less antibody avidity than males. Avidity refers to the overall strength of binding between multivalent antigens and antibodies. “This is the first

study in humans that provides evidence for a qualitatively superior antibody response in elderly adults after H1N1pdm09 vac-cination,” said lead author Dr. Surender Khurana, of the division of viral products at the Center for Biologics Evaluation and Research, US FDA, Bethesda, Maryland.

In contrast to seasonal influenza, the 2009 H1N1 pandemic disproportionately affected children and young adults. It was believed that the trend reflected the elderly population’s earlier exposure to 1918 H1N1-like viruses before 1930 or to the swine-origin H1N1 (A/NJ/76) virus in 1976, or it was simply due to repeat vac-cinations against seasonal strains.

These latest findings could be useful in evaluating the immunogenicity of new vac-cines against seasonal influenza, and its bird and swine flu variants with pandemic potential, in different age groups.

Program helps teen girls manage weight

Teenage girls gained less weight, improved their body image and ate

more nutritional meals after participating in a 6-month lifestyle modification pro-gram, shows a US study. The study, which was published online on 13 February in Pediatrics, is the first to report long-term results from a weight management pro-gram designed specifically for teenage girls.

The program was conducted in a pri-mary care setting and involved weekly peer meetings, consultations with primary care providers and separate meetings for parents.

The authors of the study said the weight

changes were statistically significant, but modest, compared to some other weight loss interventions.

The study included 208 girls, aged 12 to 17, in Oregon and Washington from 2005 to 2009. Half of them were assigned to the intervention group and half to usual care. Their initial weight was in the 85 kg range, and an average body mass index (BMI) in the 97th percentile. At the end of the study, girls who participated in the program were in the 95th percentile, while girls in the usual care group were in the 96th percen-tile. This study is part of the ongoing Kaiser Permanente research into weight loss.

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8 1-15 March 2012 Malaysia FocusEnzyme replacement therapy for lysosomal storage diseases Pank Jit Sin

Among the 50 or so types of lysosomal storage diseases (LSDs) known, six

can now be treated with enzyme replace-ment therapy (ERT) in Malaysia. The six are Gaucher’s, mucopolysaccharido-sis 1 (MPS 1), Fabry, Pompe, Hunter and Maroteaux-Lamy.

Speaking at a press briefing on LSDs, David Lin, sales and marketing manager of Genzyme Malaysia, a Sanofi company, said Malaysia currently has no definition for rare or ultra-rare diseases. LSDs fall into the category of rare or ultra-rare diseases. Depending on the country, definitions of rare or ultra-rare may differ. The US terms any disease having a prevalence of below 200,000 patients as rare, while the EU con-siders a prevalence of below five in 10,000 patients as rare. In 2004, UK’s National Institute for Health and Clinical Excellence (NICE) defined ultra-rare diseases as those with a prevalence of one in 50,000.

Made up of about 50 disorders, LSDs are caused by enzymatic deficiencies, which cause lysosomes to become engorged due to substrate accumulation. [JAMA 1999;281:249-54] As progressive accumu-lation of substrate occurs, disruption of cell and organ function occurs which can lead to serious health problems.

LSDs affect people of all ages and races. The symptoms presented differ from patient to patient and can range from very mild to very severe. Lin said: “Oftentimes, [LSDs are] progressive, debilitating and life-threatening if left untreated.”

With early diagnosis and treatment, there is hope that patients could avoid the negative symptoms of the LSDs, thus allowing them to lead normal lives.

However, this therapeutic regimen has only been shown to have a positive effect on joint mobility, lung function and orga-nomegaly, but has no influence on the manifestation of the central nervous sys-tem and cannot cure the disease. [IUBMB Life 2010;62(1):33-40]

Watch out for red flagsLin highlighted some symptoms to look out for in children with lysosomal storage disorders, including unusual facial features eg, an enlarged tongue; cloudy appear-ance of the eyes, coupled with abnormal eye movement; frequent ear infections; distended belly or protrusions from the abdomen – this is indicative of an enlarged liver, spleen or hernia; short stature as a result of failure to develop properly, cou-pled with skeletal deformities; muscle weakness, together with difficulty walking

A simple blood test can confirm the diagnosis of lysosomal storage diseases.

9 1-15 March 2012 Malaysia Focusand a decline in motor skills.

Diagnosis can be confirmed by measur-ing enzyme levels through a simple blood test. Early treatment can prevent some irreversible complications, which include organ failure.

However, it is critical for the child to be referred to a geneticist or metabolic spe-cialist familiar with the condition.

Dr. Ngu Lock Hock, a clinical geneticist

and metabolic pediatrician at Kuala Lumpur Hospital (HKL), said enzyme replacement therapy is carried out in all major MOH hospitals, with HKL being the main center.

“University hospitals also perform lim-ited ERT.” The treatment is subsidized for patients who fulfill criteria set by the gov-ernment. Currently, Ngu estimates that some 80 patients with LSDs are being treated at HKL.

New laser technology aids cataract surgerySaras Ramiya

Bladeless cataract surgery that employs a new laser technology is now avail-

able in Malaysia.LenSx® No-Blade Cataract Surgery uses

the LenSx® Femtosecond Laser System (or LenSx® Laser) to enable surgeons to per-form some of the most delicate steps of cataract surgery previously done manually.

The laser system features an integrated image-guided visualization system, which enables the surgeon to precisely plan and place all surgical incisions. It allows the surgeon to make exact corneal incisions, a perfectly centered and sized capsulotomy, and effectively fragments the lens for effi-cient removal. The lens fragments are then removed via phacoemulsification, a modi-fied ultrasound with an oscillating phaco tip that goes through the small incision to extract the fragments.

After the cataract is completely removed, the surgeon polishes the capsule at the back of the eye to diminish the conse-quence of posterior capsule opacification (secondary cataract). The final step of the

procedure is implantation of the intraocu-lar lens.

Approved by the US FDA in 2009, the laser system subsequently obtained Full Quality Assurance from the British Standards Institution (BSI) and approval from Australia’s Therapeutic Goods Administration (TGA) in 2011. LenSx Laser technology has been available in the US since 2010.

Other potential benefits of this laser technology include reduced risk of compli-cations, including blindness, and less stress to the cornea through reduced endothelial cell loss. [J Refract Surg 2009;25(12):1053-60, Curr Opin Ophthalmol 2012;23(1):33-9]

“The procedure yields effective results in visual acuity and enables shorter sur-gery time by improved positioning of the advanced technology-based intraocular lens in the eye. Patients today look for safety as well as the ability to see clearly without glasses after cataract surgery with high-end premium lenses to restore near, intermediate and distant vision,” said Dr. Aloysius Joseph Low, a consultant ophthal-mic surgeon, in a press release.

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11 1-15 March 2012 Malaysia FocusReplace warfarin only when AF is uncontrolledLeonard Yap

Despite the advent of newer and more convenient drugs for stroke preven-

tion in patients with atrial fibrillation (AF), keep your warfarin stockpiles, says a panel of experts.

If AF is perfectly under control with warfarin, there is little reason to switch to the newer class of drugs, said Datuk Dr. Jeyaindran Sinnadurai, a senior consultant pulmonary and critical care physician and head of general medicine, Kuala Lumpur Hospital. “Do not change because it is a new drug. You only change when it is ben-eficial for the patient.”

“The target of these new drugs should always be patients whose AF is not under control despite being on warfarin because they are still at risk of developing stroke.”

“You still have to exercise caution before changing to a new drug if the patient has been on an older drug [warfarin] for a long, long time. The same applies to many other fields of medicine, especially hyper-tensives. At the end of the day, you must choose the right drug for the right patients given the right circumstances,” said con-sultant cardiologist Dato’ Dr. Azhari Rosman, of the National Heart Institute, Kuala Lumpur.

“There is no perfect drug and there is no perfect solution to anything. Many people ask me, will we see the end of warfarin? I don’t think so. I don’t question that we will always have warfarin. There are going to be patients who are very stable on warfarin and we are likely not doing any service to them by trying to switch them to the newer

anticoagulants,” said Dr. Manesh Patel, John Bush Simpson assistant professor of cardiology, Duke University, US, and lead investigator of the Rivaroxaban Once-daily oral direct Factor Xa inhibition Compared with vitamin K antagonism for the preven-tion of stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) study.

“AF is the most common heart rhythm disorder, wherein the upper chambers of the heart do not squeeze effectively. This means that blood within the heart does not flow properly, pools in the atria, and clots can occur. These clots can break loose and travel through the arteries to the brain, resulting in stroke,” Jeyaindran said.

“Stroke devastates the lives of tens of thousands of patients and their families in Malaysia every year. Although the preva-lence of AF is still unknown, the incidence is on the increase as our population ages and the known risk factors for AF remain unchecked. Patients with AF are at a higher risk of more severe, disabling and fatal strokes, but the good news is that this risk can be mitigated with proper diagnosis, treatment and management,” Jeyaindran added. [Stroke in Malaysia, www.nasam.org/english/prevention-what_is_a_stroke.php Accessed on 8 February]

Warfarin has been the mainstay of stroke prevention for decades and has been reasonably successful in reducing the rate of ischemic stroke in patients with AF. Unfortunately, patients on warfarin require constant monitoring and frequent dose adjustments. They should also eat a consistent amount of foods rich in vitamin K like kale, spinach and broccoli to ensure

12 1-15 March 2012 Malaysia Focusthe international normalized ratio (INR) and prothrombin time (PT) are in the desired range. [N Engl J Med 2011;365(24):2334-5, Drug-Nutrient Interactions: Coumadin® and vitamin K Available at: ods.od.nih.gov/

pubs/factsheets/coumadin1.pdf Accessed on 8 February]

Jeyaindran, Azhari and Manesh were speaking at the launch of rivaroxaban in Kuala Lumpur recently.

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13 1-15 March 2012 Malaysia FocusLink between H. pylori and GERD debatableMalvinderjit Kaur Dhillon

The decreasing incidence of Helicobacter pylori and the increasing rate of gas-

troesophageal reflux disease (GERD) in Asia recently are not necessarily directly linked as association does not prove cau-sation, says an expert.

“Looking at data* studying H. pylori prevalence, Indians are more commonly infected compared to Malays and Chinese. We commonly speak about an inverse relationship between H. pylori and GERD because H. pylori is a biological anti-secre-tory agent, which would, therefore, suggest that Indians should have a low incidence of GERD,” said Dr. Lawrence Ho, a senior consultant at the department of medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.

“However, most erosive and non-erosive type GERD data** support that Indians suffer more commonly from GERD. This so-called inverse relationship between GERD and H. pylori in big populations is not that straightforward, suggesting to me that there are other factors interplaying between GERD and H. pylori,” said Ho.

Ho discussed robust interventional studies to demonstrate the relationship between H. pylori and GERD. One of the earliest landmark studies showed that a higher percentage of patients who had undergone H. pylori eradication developed GERD over time compared to patients who remained infected. However, Ho pointed out that this study involved different population groups and was carried out in different centres, and that there was a

possibility the results were linked together out of convenience. [Gastroenterology 1997;112:1442-7]

A Scottish study showed the reverse is true, where reflux symptoms eg, heart-burn, resolved in many patients after H. pylorieradication. [Am J Gastroenterol. 2000;95(1):101-5]

A Japanese study, on the other hand, demonstrated that H. pylori eradicated patients had an 18 percent higher inci-dence rate of esophagitis. However, a sub-group analysis found that in this study, only eradicated patients who suffered from corpus gastritis or hiatus hernia developed reflux esophagitis. [Aliment Pharmacol Ther 2000;14:729-35]

A study by Murai et al suggested that eradicating H. pylori with antibacterial therapy had no difference on the incidence of reflux esophagitis or reflux symptoms. [Aliment Pharmacol Ther 2000;14:161-5]

“There have been a lot of inconsisten-cies in the results so far. One possible reason for this is the population is too heterogeneous. So, what can we conclude from all the different studies? Does eradi-cation of H. pylori increase the incidence of esophagitis? In my opinion, the results are conflicting and any risk that is present is probably small. It is also largely dependent on corpus gastritis and hiatus hernia. If you have a large number of patients with these two conditions in your study, you will prob-ably end up with a positive co-relation,” said Ho.

* J Gastroen Hepatol 2010;25:479–86** Am. J. Gastroenterol 1998; 93: 1816-22.

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15 1-15 March 2012 Conference Coverage53rd Annual Meeting of the American Society of Hematology, 10-13 December 2011,San Diego, California, US

Aspirin reduces the risk of blood clots in VTE patients Radha Chitale

Aspirin alone reduced the incidence of recurrent blood clots in patients who suf-

fered their first venous thromboembolism (VTE), according to a recently reported trial.

In the double-blind, randomized, placebo-controlled event-driven Warfasa study, which involved patients with a first-ever VTE, a 100 mg daily dose of aspirin, administered fol-lowing a 6- to 18-month period of anticoagu-lant therapy with warfarin, reduced the risk of another event by 40 percent compared to placebo over 2 years (P=0.02).

This was the first observed benefit of aspirin in this application, said Dr. Cecilia Becattini, assistant professor of internal medicine at the University of Perugia in Italy.

She noted that VTE occurs in 800,000 people in North America alone. Emboli fragments may separate and enter pulmo-nary circulation. This sequence occurs in up to 60 percent of VTE patients and can be fatal in 20 percent of those cases.

Aspirin is known to prevent DVT in high risk patients, those with hip fractures and in post-menopausal women on estropro-gestin therapy.

Warfarin is a common, effective antico-agulant for use in VTE patients. However it needs frequent dose adjustment and is associated with bleeding risk, the worst

outcome of which could be fatal intrac-ranial embolism, making it a challenging treatment option for patients in need of long-term antithrombotic therapy.

By contrast, bleeding risk associated with aspirin is lower than 1 percent per year.

“For its safety, practicality and low cost, aspirin is a valid alternative to oral antico-agulants in the extended treatment of VTE,” Becattini said.

VTE recurrence occurred in 27 of 205 patients randomized to aspirin and in 42 out of 197 patients randomized to placebo (6.3 percent versus 11 percent patient-years).

During the study treatment period, VTE occurred in 23 and 39 patients taking aspi-rin or placebo, respectively (5.9 percent and 11 percent patient-years).

One fatal event occurred in each group and bleeding events were similar between both.

This preliminary, unpublished trial will have clinical impacts but is unlikely to change practice in the near future, Becattini said, as further studies are necessary to confirm the benefits of aspirin in patients at risk for VTEs.

Prior reports on the anticoagulant effi-cacy of aspirin in patients who already suf-fered a VTE event have been conflicting.

The researchers excluded patients with high bleeding risk, active bleeding or indica-tions for indefinite anticoagulant therapy.

For its safety, practicality and low cost, aspirin is a valid alternativeto oral anticoagulants in the extended treatment of VTE‘‘

16 1-15 March 2012 Conference Coverage53rd Annual Meeting of the American Society of Hematology, 10-13 December 2011,San Diego, California, US

Promising gene therapy cure for hemophiliaRajesh Kumar

Researchers have successfully tested a potential cure for severe hemophilia B in

six patients using gene therapy.Hemophilia is a genetic bleeding dis-

order that is caused by defective or miss-ing recombinant factor IX (FIX). Insufficient amount of this protein prevents blood from clotting normally, causing prolonged bleed-ing after an injury or surgery or, in case of severe hemophilia, even fatal spontaneous bleeding without trauma. It affects one in 30,000 men who require regular infusions of the protein.

The researchers used as a vector the adeno-associated virus (AAV) that is endemic to humans but does not cause a disease and inserted in it a normal copy of the FIX gene before infusing the virus into severe hemophilia B patients. This gene transfer approach replaced the defective gene that causes the disorder with a correct version in the patient’s liver cells, the normal site of FIX synthesis, so patients could make their own FIX, said co-researcher Dr. Andrew Davidoff, chairman of the department of surgery at St. Jude Children’s Research Hospital in Memphis, Tennessee, US.

Six patients were equally divided to receive low, intermediate and high doses of the vector carrying a normal copy of the FIX gene through an intravenous infusion in the arm, without prior immune suppressant therapy. At a follow up for 6 to 16 months post-treatment, the patients’ vector-medi-ated levels of FIX rose from <1 percent of

normal levels before the therapy to between 2 and 12 percent of normal levels.

Such moderate increases in FIX levels can significantly impact patients’ symptoms and quality of life. Four of the 6 study patients, for instance, stopped prophylactic treatment and remained free of spontaneous bleed-ing, while the remaining two increased time interval between their FIX infusions, said the researchers.

“We have developed a vector for gene transfer that is more efficient and effective than traditional treatment for patients with severe hemophilia B by preventing spon-taneous bleeding in this high risk patient population,” said lead researcher Dr. Amit Nathwani of the department of hematol-ogy at the UCL Cancer Institute in London, UK. “Our novel approach shows promise for improved gene therapy for hemophilia B and other protein deficiencies.”

The AAV has proved to be a promising vector for FIX gene delivery. It can transduce liver very efficiently and is less likely to stimu-late an immune response to transduced cells than other vectors since no viral proteins are expressed, Nathwani later added, saying this facilitates long-term expression of the FIX transgene following a single administration.

Immune-mediated clearance of the AAV-transduced liver cells appeared as a con-cern, but researchers said this process could be controlled with a short course of steroids without loss of transgene expression. They now plan to treat more patients at the high dose of vector without giving them immu-nosuppression.

MTAPR15-11/001

Medical Editor Dr. Kumaran Ramakrishnan

Editorial Advisory Board - Malaysia

Hepatology Tan Sri Dato' Seri Dr. Mohd Ismail Merican

Cardiology Dato’ Dr. Khoo Kah LinPantai Medical Centre

Clinical Oncology Assoc. Prof. Dato' Dr. Fuad Ismail Hospital Universiti Kebangsaan Malaysia

Urology Prof. Dato’ Dr. SahabudinRaja Mohamed Prince Court Medical Centre

Gastroenterology Prof. Dato’ Dr. Goh Khean LeeUniversity Malaya Medical Centre

ENT Prof. Dato’ Dr. Balwant Singh GendehHospital UniversitiKebangsaan Malaysia

Family Medicine Prof. Datin Dr. Chia Yook ChinUniversity Malaya Medical Centre

Endocrinology Dr. Chan Siew Pheng

Sime Darby Medical Centre

Respiratory Datuk Dr. Aziah Ahmad MahayiddinMedicine Institute of Respiratory Medicine

Anesthesiology Prof. Dr. Ramani VijayanUniversity Malaya Medical Centre

Infectious Diseases Prof. Dr. Adeeba KamarulzamanUniversity Malaya Medical Centre

Psychiatry Prof. Dr. Mohamad Hussain HabilUniversity Malaya Medical Centre

O&G Dato’ Dr. Ravindran JegasothyHospital Kuala Lumpur

Dermatology Dr. Steven KW ChowPantai Medical Centre

Genito-Urinary Dr. Doshi Hemendra KumarMedicine Klinik Kulit & Kelamin Shriji

Radiology Prof. Dr. John George FRCR (UK) University Malaya Medical Centre

School absenteeism linked to mental health problems

Students who are frequently absent from school are more likely to have symptoms of psychiatric disorders later on in

adolescence, shows a US study. The longitudinal study of more than 17,000 youths also found

that mental health problems, such as antisocial behavior or de-pression, during one year also predicted missing additional school days in the following year for students in middle and high school.

The study, published in Child Development, was conducted by researchers at the University of California, Los Angeles (UCLA), the University of Florida, Boston University, the Child and Ado-lescent Services Research Center, the Oregon Social Learning Center, and Johns Hopkins University.

“School personnel in mid-dle schools and high schools could bene t from knowing that mental health issues and school absenteeism each in u-ence the other over time. Help-ing students address mental health issues may, in turn, help prevent the emergence of chronic absenteeism. At the same time, working to help students who are developing a pattern of chronic absenteeism come to school more consis-tently may help prevent psy-chiatric problems,” said lead author Jeffrey Wood, an asso-ciate professor of educational psychology and psychiatry at UCLA.

Hepatitis risk from nail salons, barbershops

The risk of hepatitis B or C transmission at nail salons and barbershops cannot be excluded if nail les, razors, clippers and scissors are not

routinely disinfected, according to a study.Customers should be aware of the potential risks and take precautions

including asking questions to determine whether or not the salons are properly cleaning and disinfecting tools and equipment, said researcher Dr. David Johnson, of the Eastern Virginia Medical School, US, who reviewed 18 published papers to establish the connection.

The results were presented at the recent annual scienti c meeting of the American College of Gastroenterol-ogy held in Washington DC., US.

“Healthcare providers need to be aware of these risks – both for appropriate counseling of their patients, and when assessing possible causality in patients with hepatitis B or C,” said Johnson, while recommending neces-sary training for barbers and nail technicians.

Medica l B r ie fs 1-15 February 2012 03

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18 1-15 March 2012 Conference Coverage53rd Annual Meeting of the American Society of Hematology, 10-13 December 2011,San Diego, California, US

Novel BTK inhibitor holds potential in CLLMichael Kaufman

Updated findings from a multicenter phase Ib/II clinical trial, presented at

the 2011 American Society of Hematology (ASH) Annual Meeting and Exposition, suggest that the novel Bruton’s tyrosine kinase (BTK) inhibitor PCI-32765 may be an important new targeted treatment for patients with chronic lymphocytic leuke-mia (CLL).

“BTK is a central mediator of B-cell receptor signaling essential for normal B-cell development,” explained lead author Professor Susan O’Brien of the Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston. This makes it a primary target for research on B-cell malignancies such as non-Hodgkin’s lymphoma (NHL).

PCI-32765, an orally-administered irre-versible inhibitor of BTK, induces apop-tosis and inhibits cellular migration and adhesion in malignant B-cells. An early analysis of the phase Ib/II study showed PCI-32765 to be “highly active and toler-able” in patients with CLL. Longer term follow-up was presented by O’Brien.

Two cohorts of patients with relapsed or refractory (R/R) CLL/small lymphocytic lymphoma (SLL) were treated with PCI-32765 at daily doses of either 420 mg (n=27) or 840 mg (n=34) for 28-day cycles until disease progression. Patients in the 420 mg arm had a median of three prior treatment regimens vs a median of five in the 840 mg arm. Seventy-two percent

of participating patients had at least one poor-risk molecular feature.

In the current analysis, researchers concluded that PCI-32765 was associ-ated with high rates of 6-month pro-gression-free survival (PFS) in patients with relapsed CLL. At 10-month follow-up, 70 percent of patients in the 420 mg treatment group achieved an objective response (OR) to therapy (previously reported as 48 percent), and 44 percent of patients in the 840 mg cohort achieved an OR at 6-month follow-up.

An additional 19 percent of the 420 mg cohort and 35 percent of the 840 mg cohort had a “nodal partial response”, represented by a ≥50 percent reduction in lymph node size but with some lymph nodules persisting. The researchers emphasized that 82 percent of patients remain on treatment, whereas 8 percent have experienced progressive disease.

Two patients discontinued the trial because of adverse events, and six required dose reduction. The most fre-quently reported adverse events were mild and included diarrhea, fatigue, nau-sea, and skin bruising.

Serious adverse events (SAEs), which are common among this immune-com-promised patient population, occurred in 38 percent of patients, with 10 per-cent considered potentially related to treatment. The majority of patients also experienced a transient high lymphocyte count during the first 2 months of treat-ment that resolved over time, which is

19 1-15 March 2012 Conference Coverage53rd Annual Meeting of the American Society of Hematology, 10-13 December 2011,San Diego, California, US

another typical characteristic of treat-ment in this patient group.

“Our results suggest that PC-32765 has the potential to be highly effective and tolerable, and, more importantly, appears to be working well in patients with poor prognoses,” said O’Brien. “As we become better equipped to target specific cellular functions, it is our hope that therapies like PCI-32765 will become effective interventions to manage disease in patients with CLL.”

The investigators concluded that PCI-32765 is well tolerated with high rates of

6-month PFS in R/R CLL/ SLL. Phase III tri-als of PCI-32765 in CLL/ SLL are planned.

“One of the most exciting things about agents like PCI-32765 is that they are not myelosuppressive,” said O’Brien. “This is a big deal in CLL because one of the biggest problems we have with treat-ment is that all the treatments we have are chemo-based, and the biggest com-plication with practically every agent we have is myelosuppression and infection,” which are of special concern in patients with CLL who are already immunocom-promised.

20 1-15 March 2012 RegionalLate-presenting fetal disorder on the riseChristina Lau

Late-presenting fetal hemoglobin (Hb) Bart’s disease has re-emerged in Hong

Kong recently, although the city’s universal antenatal screening and prenatal diagnosis program implemented in the public sector since 2000 has led to a dramatic reduction in the prevalence of this condition.

The re-emergence was reported in a case series published recently in the Hong Kong Medical Journal. The study, conducted in the obstetric units of Princess Margaret Hospital and Kwong Wah Hospital from January 2000 to December 2009, found 13 (22 percent) late-presenting cases of Hb Bart’s disease out of a total of 59. All late presenters were identified from 2003 onwards, and were only diagnosed after 24 weeks of gestation. [Hong Kong Med J 2011;17:434-40]

According to the authors, the late pres-entations were related to an influx of obstetric patients who had not undergone proper antenatal screening and diagno-sis of thalassemia. Significant associations were found between late presentations and non-eligible obstetric patients (69 percent versus 11 percent for early presentations), non-booked status at the antenatal service (62 versus 0 percent), and unavailability of partner’s mean corpuscular volume (MCV) status (23 versus 0 percent).

“Reasons for not making the diagnosis in early pregnancy included late or no book-ing at our antenatal services, defaulting of follow-up, improper implementation of screening or diagnostic procedures, and possibility of non-paternity,” they reported.

Given the poor maternal and perinatal

outcomes associated with fetal Hb Bart’s dis-ease, the authors urged better patient and doctor education, both in mainland China and in Hong Kong, to stress the importance of early diagnosis and the serious complica-tions due to late presentations.“Maternal low MCV and characteristic prenatal ultra-sound features, such as cardiomegaly, pla-centomegaly and hydrops fetalis, are useful for detecting affected pregnancies in this group of patients [patients without proper antenatal screening and diagnosis of thalas-semia],” they wrote. “A late-booking woman with a low MCV and suspected fetal Hb Bart’s disease should be referred to a mater-nal fetal medicine specialist for ultrasound assessment and consideration of invasive diagnostic testing.”

In the study, mothers presenting late with fetal Hb Bart’s disease were significantly more likely to have symptoms or signs (85 versus 0 percent) and to suffer from ges-tational hypertensive disorder (54 versus 0 percent). The most common ultrasound feature of affected pregnancies was placen-tomegaly (98 percent), followed by cardio-megaly (94 percent) and hydrops fetalis (77 percent). The perinatal mortality rate was 85 percent in late presentations.

In addition to better education, increased vigilance among general obste-tricians in mainland China and Hong Kong is another factor crucial for tackling the re-emergence of late-presenting fetal Hb Bart’s disease in Hong Kong, wrote Dr. TN Leung, of the Obstetrics and Gynecology Center, Hong Kong Sanatorium & Hospital, in a related editorial. [Hong Kong Med J 2011;17:432-3]

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22 1-15 March 2012 RegionalHarnessing the web to improve diabetes careNaomi Rodrig

An innovative web-based program com-bining risk stratification, clinical deci-

sion support and protocol-driven care can significantly improve ambulatory diabetes care, according to Professor Juliana Chan, of the Chinese University of Hong Kong (CUHK), who introduced the program and its accomplishments at a recent press con-ference. [BMC Medical Informatics and Decision Making 2010;10:6]

“Diabetes is considered a ‘silent killer’. Undiagnosed or suboptimally managed diabetes nearly doubles the risk of death and reduces life expectancy by at least 6 years due to major complications such as stroke, heart disease, kidney failure and cancer,” she said. “Approximately one in four people with diabetes develop serious complications in 5 years if not properly managed. However, diabetes-associated complications are preventable and manageable.”

Indeed, a 50 to 70 percent risk reduc-tion has been reported among patients receiving protocol-driven care delivered by a multidisciplinary team. [Diabetes Care 2007;30:953-9]

To facilitate diabetes care for healthcare professionals and patients alike, the Asia Diabetes Foundation (ADF) had launched the Joint Asia Diabetes Evaluation (JADE) program, which uses an information tech-nology platform to promote structured and collaborative care. “ADF is a non-profit organization of the CUHK aiming to improve the management of diabetes and other chronic diseases,” added Chan, who

is ADF’s CEO. “The JADE program, in operation since

2007, is managed by leading diabetes spe-cialists from eight Asian countries, who pro-vide overall direction and monitoring, while also helping to promote its adoption and use in their respective countries,” Chan told Medical Tribune.

Using data from a comprehensive dia-betes registry, the group has developed a series of questions to predict risk of all-cause death and cardiovascular and renal complications in Chinese patients with type 2 diabetes. Validation studies con-firmed that the JADE risk engine success-fully categorizes type 2 diabetes patients into four different risk levels, which, in turn, helps to guide clinical management. [Diabet Med 2009;26:693-9]

Based on each patient’s risk level, a care protocol with predefined schedules and decision support is generated, including recommended intervals between visits, laboratory tests and complication assess-ments. Should the risk level change, the management plan is automatically adapted

Doctors and patients participating in the JADE program.

23 1-15 March 2012 Regionalto promote treatment to target and cost-effective use of resources.

“Although we know the risks of diabetes complications, successful treatment to tar-get and good glycemic control are very dif-ficult to achieve in practice,” noted Chan. “JADE is a regional quality improvement program that aims to translate evidence into practice using information technol-ogy. The e-portal is designed specifically for Asian patients in terms of risk equa-tions and language requirements.”

She explained that patient data collected at each visit are displayed clearly in a printa-ble report, showing risk predictions, trends of risk-factor control and practice tips for healthcare providers. Self-management tips for patients can be generated in five Asian languages, including traditional and

simplified Chinese, Korean, Malay and Thai, as well as English. “Furthermore, the e-portal provides matrices to help doc-tors monitor patients’ adherence to treat-ment,” added Chan.

The JADE program is primarily led and monitored by diabetes nurses at CUHK’s Yao Chung Kit Diabetes Assessment Center. “This model saves physicians’ time and resources as the nurse monitor can alert the respective GP or family doctor only when any irregular data are observed,” she pointed out. “Using JADE, the rate of attainment of treatment targets among participating patients has improved by 70 percent. We are hoping that the program will be more widely adopted by physicians across Asia to upgrade diabetes manage-ment in the region.”

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24 1-15 March 2012 Internat ionalOverweight docs less likely to advise obese patients on weight lossPank Jit Sin

An American survey has revealed what we all know to be common sense – the pot doesn’t like calling the kettle ‘black.’

The survey showed that a physician’s body mass index (BMI) may directly influ-ence his or her ability to deal with a patient’s overweight status.

Appearing in the online version of Obesity, the study found that doctors with normal BMI were more likely to touch on the topic of weight loss with their overweight or obese patients (30 percent of those with normal BMI versus 18 percent of those who were overweight, P =0.010).

Head researcher Sara Bleich (PhD) and co-researchers at the Johns Hopkins Bloomberg School of Public Health and Medical Institutions in Baltimore, reported that normal-weight physicians, compared to their overweight or obese colleagues, had more confidence in their ability to counsel patients on diet (53 percent versus 37 per-cent, P=0.002) and exercise (56 percent ver-sus 38 percent, P=0.001).

The 498 study participants included GPs, family physicians and general internists. They were given a 49-item questionnaire on topics such as how they recorded an obesity diagnosis; how they initiated weight loss discussions; how they rated self-efficacy for providing counseling; and how they pre-scribed weight reduction medications when such a situation was indicated.

They further looked into differences in outlook on modeling healthy behaviors and whether they believed that a patient’s trust

in a doctor’s advice might be less if the doc-tor was overweight or obese.

The study concluded that normal-weight doctors were more likely to believe that doc-tors should model weight-related behav-iors such as maintaining a healthy weight (72 percent versus 56 percent, P=0.002) and exercising regularly (73 percent versus 57 percent, P=0.001) compared to their overweight or obese colleagues. The same healthy weight doctors also believed that overweight or obese patients would be less likely to take advice given by a doctor who was overweight or obese.

The study also revealed that physicians’ impressions of themselves could affect their likelihood of diagnosing a patient with obesity. They were more likely to diagnose a patient as being overweight (93 percent versus 7 percent, P<0.001) and to bring up the subject of weight loss (89 percent versus 11 percent, P<0.001) if they perceived the patient’s body weight exceeded their own.

There were, however, limitations to the study as it included the use of a cross-sectional analysis which only allowed the

25 1-15 March 2012 Internat ional

UK switching to quadrivalent HPV vaccine in Sept Saras Ramiya

Beginning in September, a quadrivalent vaccine will be used in the human papillo-

mavirus (HPV) vaccination program in schools, says the UK Department of Health (DOH).

The vaccine protects against HPV16 and HPV18 that cause more than 70 percent of cervical cancer in England, and HPV6 and HPV11 that cause 90 percent of genital warts.

The HPV program was implemented in September 2008 following advice from independent experts on immunization. The Joint Committee on Vaccination and Immunisation recommended that the HPV vaccine be offered routinely to girls aged 12 to 13 years. The DOH also offered a catch-up program for girls up to 18 years of age. Since then, 1.5 million young women and girls have been vaccinated.

According to Professor David Salisbury, the Government’s director of immuniza-tion, “It’s not unusual for the NHS [National Health Service] to change vaccines or other medicines – it can happen following com-petitive tendering exercises or when new research findings come to light.”

The DOH has been offering the bivalent HPV vaccine and decided to switch to the quadrivalent vaccine, which protects against

four types of HPV. [Key vaccine information: HPV. www.dh.gov.uk/en/Publichealth/Immunisation/Keyvaccineinformation/DH_104010 Accessed on 9 February, BMJ 2011;343:d5775,2010;341:c3493, Lancet 2007;369(9574):1693-702]

“Young women and girls who have already been vaccinated or who are due to be vac-cinated before September do not need to be vaccinated again. They have done exactly the right thing and they can be assured that they are protected against types of HPV virus that cause over 70 percent of cervical cancer.

“We have one of the best HPV vaccina-tion programs in the world and we want that success to continue. It will be tremendous to see rates of cervical cancer falling. The num-ber of women getting abnormal results from HPV screening will also fall. Many women will no longer have to live through the worry and stress of follow-up after screening, including treatment for precancerous lesions.”

Primary Care Trusts (PCTs) are responsi-ble for the delivery of the vaccination pro-gram in their local areas. A school-based program is recommended by the DOH for the routine vaccination program, as vac-cination will be delivered most efficiently through schools. Some PCTs chose to implement a GP-based program.

determination of associations and not causal relationships. Furthermore, self-reporting by the physicians could have caused an underestimation of those in the overweight/obese group.

The researchers concluded that “physician

self-efficacy to care for obese patients, regardless of their BMI, may be improved by targeting physician wellbeing and enhanc-ing the quality of obesity-related training in medical school, residency or continuous medical education.”

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27 1-15 March 2012 Internat ionalAcupuncture improves chemo-induced painRadha Chitale

Cancer patients who develop peripheral neuropathy as a result of chemotherapy

may be able to turn to acupuncture to relieve their pain, according to data from a small pilot study.

Currently, there are no effective treat-ments for chemotherapy-induced peripheral neuropathy (CIPN), which causes pain and difficulty walking as a result of nerve damage and can lead patients to stop chemotherapy.

The study included 192 patients diagnosed with peripheral neuropathy based on nerve conduction studies. Eleven of those patients were identified as having CIPN as the under-lying cause of pain. They were receiving chemotherapy for different types of cancer. Six of those 11 patients agreed to undergo acupuncture treatments while the remaining five served as controls. [Acupunct Med 2011 Dec 5. Epub ahead of print]

The test group received 10 weeks of acu-puncture treatment in the legs. All 11 patients received appropriate care otherwise. They received no other pain treatments except carbamazepine or pregabalin during the observation period.

Nerve conduction studies were carried out initially and again after 6 months. Patients were asked to rate whether their pain had worsened, improved or stayed the same.

Five out of the six patients receiving acu-puncture treatments and two out of five control patients reported an improved con-dition. The remaining patients reported no change in their pain.

“These findings are of special significance since PN is otherwise almost untreatable but

seems to respond to treatment by acupunc-ture,” the researchers said.

Previous studies from the same research group on peripheral neuropathy from a vari-ety of causes, including diabetes, showed that a few months of acupuncture improved nerve conduction in three-fourths of patients.

Among chemotherapy drugs, taxanes, vinca alkaloids and platinum compounds are most frequently associated with peripheral neuropathy.

Though peripheral neuropathy can have many causes, damage to the axons, demyeli-nation, or both are what causes pain.

“One may speculate that repeated thera-peutic interventions with acupuncture over a period of 10 weeks improves the symp-tomatic state of peripheral neuropathy and also induces a normalization of histological morphology,” the researchers said.

Acupuncture may also increase blood flow and promote nerve healing.

The researchers concluded that the posi-tive results from this non-blinded, non-rand-omized study support further objective study on the use of acupuncture for CIPN.

A small pilot study suggests that acupuncture may be effective in alleviating chemotherapy-induced peripheral neuropathy.

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31 1-15 March 2012 Calendar

MALAYSIAn EVEnTSMarch Coloproctology 20128/3 to 10/3; KuchingInfo : SecretariatTel : (03) 4023 4700 / : 4025 4700Fax : (03) 4023 8100Email : secretariat@colorectalmy.orgwww.colorectalmy.org

13th Malaysian Congress and Exhibition on Allergy and Immunology9/3 to 11/3; Kuala LumpurInfo : MSAI SecretariatTel : (03) 4041 0092 / : 4041 6336Fax : (03) 4042 6970 / : 404207919Email : dr_harnam@hotmail.comwww.allergymsai.org

15th Ottawa Conference9/3 to 15/3; Kuala LumpurInfo : SecretariatTel : (03) 4252 9100Fax : (03) 4257 1133Email : ottawa2012@aosconventions.comwww.ottawaconference.org

1st World Congress on Healthy Ageing 201219/3 to 22/3; Kuala LumpurInfo : SecretariatTel : (03) 2070 5600Fax : (03) 2072 5600Email : wcha@healthyageing.orgwww.healthyageingcongress.org

8th National Symposium on Adolescent Health (8th NSOAH)23/3 to 25/3; Melaka

Info : Dr. N. Thiyagar / Dr. Mymoon AliasTel : (03) 20954784Fax : (03) 20954784Email : mymoon_kkm@hotmail.com / thiyagarsp@yahoo.comwww.mma.org.my

National TB Symposium 201224/3 to 25/3; Kuala Lumpur Info : Dr. Liza Ahmad Fisal / Dr. Nurhayati Mohd Marzuki / Dr. ZamzurinaTel : (03) 4023 2966Fax : (03) 4024 4063Email : lizafaisal77@yahoo.com / nurmm25@gmail.com / zamzurina76@yahoo.com.mywww.nationaltbsymposium.webs.com

Endoscopy 201230/3 to 1/4; Kuala LumpurInfo : MSGH SecretariatTel : (03) 4024 4700 / : 4025 4700 / : 4025 3700Fax : (03) 40230 8100Email : secretariat@msgh.org.mywww.msgh.org.my

AprilNutrition and Dietetics Professional Competency Symposium6/4 to 7/4; Kuala LumpurInfo : Ms Grace ChongTel : (03) 2162 0566Fax : (03) 2161 6560Email : ndpcs@console.com.my

32 1-15 March 2012 Calendar19th Annual Congress of the Perinatal Society of Malaysia12/4 to 15/4; Petaling JayaInfo : SecretariatTel : (03) 2615 5555 / : 2615 6889 Fax : (03) 2694 8187Email : perinatalsocietymalaysia@ yahoo.comwww.perinatal-malaysia.org

Annual Scientific Meeting of the Malaysian Society of Anaesthesiologists & College of Anaesthesiologists, AMM 201219/4 to 22/4; KuantanInfo : SecretariatTel : (03) 4023 4700 / : 4025 4700Fax : (03) 4023 8100Email : secretariat@msa.asm.org.mywww.msa.asm.org.my

6th General Assembly of Asia Pacific Organization for Cancer Prevention (APOCP 2012)26/4 to 29/4; KuchingInfo : Professor Yip Cheng HarTel : (03) 7949 2440Fax : (03) 7958 6360Email : yipch@um.edu.my/ yipch@ummc.edu.mywww.apocp.net

9th Malaysian Conference and Exhibition on Anti-Aging, Aesthetic, and Regenerative Medicine & 2nd International Congress on Anti-Aging, Aesthetic, and Regenerative Medicine27/4 to 29/4; Kuala LumpurInfo : SecretariatTel : (03) 4041 0092 / : 4041 6336Fax : (03) 4042 6970 / :4042 7919Email : info@saamm.com

www.saaarmm.org

WFAS 2012 Malaysia: Acupuncture, Orthopedic, Cancer and Education Symposium30/4 to 2/5; KuchingInfo : Professor Liao ChunhuaTel : (03) 5510 6868 ext 683Fax : (03) 9173 9369Email : chliao@msu.edu.mywww.msu.edu.my

MayPrivate Medical Practitioners’ Association of Selangor and Kuala Lumpur 52nd AGM & Annual Scientific Meeting 5/5 to 6/5; Kuala LumpurInfo : SecretariatTel : (03) 4023 4700 / : 4025 4700 Fax : (03) 4023 8100Email : acadmed@po.jaring.mywww.pmpaskl.org

AGM/Annual Scientific Meeting of the College of Surgeons, Academy of Medicine of Malaysia25/5 to 27/5; KuantanInfo : SecretariatTel : (03) 4023 4700/ : 4025 4700Fax : (03) 4023 8100Email : acadmed@po.jaring.mywww.acadmed.org.my

33 1-15 March 2012 Calendar

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 Parenteral & Enteral Nutrition Society of Malaysia (PENSMA) 201214/6 to 16/6; PenangInfo : SecretariatTel : (03) 4023 4700 / 4025 4700 / : 4025 3700Fax : (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

Inaugural Asean Sleep Congress & 4th Malaysian International ORL-HNS Congress 28/6 to 30/6; Kuala LumpurInfo : SecretariatTel : (03) 2233 8931 / 2233 8932Fax : (03) 2233 8899Email : aseansleep2012@gmail.comwww.aseansleepcongress.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 4700 : 4025 3700Fax : (03) 4023 8100Email : secretariat@msgh.org.mywww.msgh.org.my

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

1st Asia Pacific Conference on Clinical Epidemiology and 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; PenangInfo : SecretariatEmail : secretariat@msr.mywww.msr.org.my

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

34 1-15 March 2012 Calendar

InTERnATIOnAL EVEnTS

MarchERC 2012: European Congress of Radiology1/3 to 5/3; Vienna, AustriaInfo : European Society of RadiologyEmail : registration@myESR.org www.myesr.org/cms/website. php?id=/en/ecr_2012.htm

2012 Annual Meeting of the Academy of Allergy, Asthma & Immunology2/3 to 6/3; Orlando, Florida, USInfo : SecretariatEmail : annualmeeting@aaaai.org www.aaaai.org

2012 Highlights of ASH® in Asia3/3 to 4/3; SingaporeInfo : ASH Customer Relations DepartmentEmail : customerservice@hematology. org www.hematology.org/ Meetings/Highlights/6836.aspx

13th Pan American Congress of Neurology5/3 to 8/3; La Paz, BoliviaInfo : World Federation of Neurology Email : pcn2012@kenes.com www2kenes.com/pcn2012/ pages/Home.aspx

20th Annual Meeting of the Asian Society for Cardiothoracic Surgery8/3 to 11/3; Bali, IndonesiaInfo : Asian Society for Cardiothoracic SurgeryEmail : info@ascvtsbali2012.org www.ascvtbali2012.org

61st American College of Cardiology (ACC) Annual Scientific Session24/3 to 27/3; Chicago, Illinois, USInfo : SecretariatEmail : accregistration@jspargo.com www.accscientificsession.org/

15th World Congress of Anaesthesiologists25/3 to 30/3; Buenos Aires, ArgentinaInfo : WF SA World Congress of AnaesthesiologistsEmail : wfsahq@anaesthesiologists.org www.wca2012.com

9th European Congress on Menopause28/3 to 31/3; Athens, GreeceInfo : European Menopause and Andropause SocietyEmail : emas@kenes.com www.2.kenes.com/emas/pages/ default/aspx

35 1-15 March 2012 Calendar

AprilWorld Congress of Cardiology (WCC) Scientific Sessions18/4 to 21/4; Dubai, UAEInfo : SecretariatEmail : wcc2012reg@mci-group.com www.worldcardiocongress.org

24thEuropean Congress of Ultrasound in Medicine and Biology22/4 to 24/4; Madrid, SpainInfo : SecretariatEmail : info@euroson2012.com www.euroson2012.com

III NWAC World Anesthesia Convention (NWAC 2012)24/4 to 28/4; Istanbul, TurkeyInfo : SecretariatEmail : nwac@kenes.com www.nwac.org

May19th WONCA Asia Pacific Regional Conference24/5 to 27/5; Jeju Island, S. KoreaInfo : SecretariatEmail : admin@woncaap2012.org www.woncaap2012.org

American Thoracic Society (ATS) International Conference 201218/5 to 23/5; San Francisco, California, US

Info : SecretariatEmail : atsinfo@thoracic,org http://conference.thoracic. org/2012/

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Editorial Advisory Board - Malaysia

Hepatology Tan Sri Dato' Seri Dr. Mohd Ismail MericanCardiology Dato’ Dr. Khoo Kah Lin Pantai Medical CentreClinical Oncology Assoc. Prof. Dato' Dr. Fuad Ismail Hospital Universiti Kebangsaan MalaysiaUrology 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 CentreRespiratory Datuk Dr. Aziah Ahmad Mahayiddin Medicine Institute of Respiratory MedicineAnesthesiology Prof. Dr. Ramani Vijayan

University Malaya Medical CentreInfectious Diseases Prof. Dr. Adeeba Kamarulzaman

University Malaya Medical CentrePsychiatry Prof. Dr. Mohamad Hussain Habil

University Malaya Medical CentreO&G Dato’ Dr. Ravindran Jegasothy

Hospital Kuala LumpurDermatology Dr. Steven KW Chow

Pantai Medical CentreGenito-Urinary Dr. Doshi Hemendra Kumar Medicine Klinik Kulit & Kelamin ShrijiRadiology Prof. Dr. John George FRCR (UK) University Malaya Medical Centre

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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 checking 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 therefrom. 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, photocopying, recording or otherwise), without the written consent of the copyright owner. Permission to reprint must be obtained from the publisher. Advertisements 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 Office under Permit No. PS-326-01 NCR, dated 9 Feb 2001. Printed in Malaysia by KHL Printing Co Sdn Bhd.

PP17111/12/2012 (031349) ISSN 1608-5086