New advisory recommends fewer ...enews.mims.com/landingpages/mt/pdf/Medical_Tribune_February_2013_MY.pdf · MT Cameo OFC Delfi Novalac.pdf 1 12/19/12 12:19 PM FORUM Traditional medicine

1-15 February 2013

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MALAYSIA FOCUSREGIONALRecognizing the herd effect benefits of pneumococcal vaccination

POLARIS initiative hones in on personalized medicine

New advisory recommends fewer endoscopies for GERD

MT Cameo OFC Delfi Novalac.pdf 1 12/19/12 12:19 PM

FORUM

Traditional medicine in mainstream healthcare system

2 1-15 February 2013

New advisory recommends fewer endoscopies for GERD

Radha Chitale

New recommendations for patients with gastroesophageal reflux dis-ease (GERD) advise physicians to

avoid unnecessary endoscopies in patients for whom there is little benefit.

Upper endoscopy is a routine procedure for GERD diagnosis and management, par-ticularly when monitoring for abnormal or cancerous esophageal tissue, but overuse re-sults in higher healthcare costs and adverse side effects without improved patient out-comes.

“Limited data suggest that clinicians who care for patients with GERD symptoms often do not follow suggested practice,” according to the Clinical Guidelines Committee of the American College of Physicians.

The committee noted that 10-40 percent of upper endoscopies are not “generally in-dicated” but are performed for patients with GERD symptoms without additional dyspla-sia, are performed too often, or are performed before alarm symptoms occur.

The best practice recommendations indi-cate upper endoscopy for patients with heart-burn and alarm symptoms including dyspha-gia, bleeding, anemia, weight loss or recurrent vomiting. [Ann Intern Med 2012;157:808-816]

Upper endoscopy is also indicated for pa-tients who persist with GERD symptoms even after a 4-8-week course of acid-reducing pro-ton pump inhibitor therapy, who persist with severe esophagitis, or who have a history of a narrowed esophagus.

Persistent GERD can lead to Barrett’s esopha-gus, in which the esophageal lining erodes and is replaced by stomach lining tissue, and both are associated with increased risk of esopha-geal adenocarcinoma. However, 80 percent of all cancers occur in men, so screening for can-cer or Barrett’s esophagus via endoscopy is rec-ommended for men over 50 with GERD.

“If endoscopic screening of patients with GERD symptoms is to be pursued, men older than 50 years will provide the highest yield of both Barrett’s esophagus and early adenocar-cinoma,” the researchers said.

But both men and women with a history of Barrett’s esophagus may be screened every 3-5 years via endoscopy for dysplasia or can-cerous cells.

Up to 85 percent of GERD patients have non-erosive reflux disease.

And while upper endoscopy is a relatively low-risk procedure, it can cause respiratory failure, hypotension, reactions to anesthetics, and in extreme cases, perforation and cardio-vascular events.

The committee based its recommendations on a literature review and comparison of clin-ical guidelines from other professional orga-nizations.

“Because of its high prevalence in the gen-eral population, care of patients with GERD is largely within the domain of primary care providers,” they said. “Upper endoscopy is not an appropriate first step in most patients with GERD symptoms and is indicated only when empirical PPI therapy for 4-8 weeks is unsuccessful.”

3 1-15 February 2013 Forum

Traditional medicine in mainstream healthcare systemExcerpted from the officiating speech of Dato’ Sri Liow Tiong Lai, Minister of Health, Malaysia, at the 4th Conference on Traditional Medicine in ASEAN Countries, Kuala Lumpur.

Forty-five years ago ie, in August 1967, ASEAN [Association of Southeast Asian Nations] was born. One of its founding

aims was to promote active collaboration and mutual assistance amongst member states on matters of common interest in the economic, social, cultural, technical, scientific and ad-ministrative fields. Today, it can be considered to be amongst the most successful inter-gov-ernmental organizations in the developing world.

The WHO defines ‘traditional medicine’ as the sum total of knowledge, skills and prac-tices on holistic healthcare, which are recog-nized and accepted by the community for its role in the maintenance of health as well as the treatment of certain diseases. It is based on theory as well as the beliefs and experienc-es that are indigenous to the various cultures, and is developed and handed down from generation to generation.

The value of traditional medicine since ancient times is well known and evident. It has been part of the healthcare practices of this part of the world for many millennia. However, as we have noted, the indigenous knowledge of our forefathers and revered traditional medicine practices are often not fully documented, but passed down through oral traditions. With the passage of time, such knowledge may be lost forever. The passing on of this indigenous knowledge of tradition-al medicine to the younger generation, even if it occurs, may not be total or complete. Many a time, the knowledge is transmitted in parts. Because it is based on memory, recall may be suboptimal. To elicit total recall is often dif-ficult, especially when one is trying to tap the weary minds of senior traditional medicine

practitioners, who are still practicing in the twilight of their lives, for the benefit of the community. Inevitably, this will lead to some erosion or dilution of the invaluable knowl-edge that could have benefited the commu-nity at large. Therefore, it is our responsibility to ensure the documentation of this knowl-edge in traditional medicine and to propagate and utilize it for the benefit of the community, country and the world.

It is a well-known adage that ‘Health is wealth’ and that the health sector these days not only generates wealth in the form of healthy, productive citizens, but also contrib-utes directly to the nation’s economic prosper-ity. Realizing this potential in healthcare, the Malaysian government has chosen healthcare as one of the 12 important sectors in the Na-tional Key Economic Areas of the Economic Transformation Programme.

With the potential of economic gain in the healthcare sector, and this includes tra-ditional medicine, we have to ensure that the services provided are up to international standards. Only then will foreign and local patients be drawn to partake of traditional medicine treatment from this part of the world.

Thus, the importance of evidence-based healthcare in all our undertakings. Evi-dence-based healthcare is the current buzz-word shaping the healthcare scenario be-cause evidence of efficacy and safety are paramount when it comes to health and healthcare. Traditional medicine has some way to go before it is fully incorporated into the existing mainstream healthcare system, but I am pleased that much effort is being made to achieve this goal, especially with

4 1-15 February 2013 Forumrespect to the scientific aspects of tradition-al medicine. We live in an era of evidence-based decision-making, so it is important to ensure the efficacy and safety of the treat-ment that we provide to our ever-discern-ing and knowledgeable customers.

In order to attain international recognition and support, it is important to establish an accepted standard or a framework that can be adopted and adapted by ASEAN member states. This includes a framework for practice and services of traditional medicine, enforce-ment and regulation, research, training and education, and integrative medicine.

Recently, the WHO published The Regional Strategy for Traditional Medicine in the Western Pacific 2011-2020. The WHO has recognized five key strategic objectives for Western Pa-cific countries to attain by taking into con-sideration each country’s individual needs, capacity, priorities, existing health policies, strategies, legislation, resources, culture and history. These five key strategic objectives are for countries to:

• include traditional medicine in the national health system,

• promote safe and effective use of traditional medicine,

• increase access to safe and effective traditional medicine,

• promote protection and sustainable use of traditional medicine resources,

• strengthen cooperation in generating and sharing traditional medicine knowledge and skills.

It is sincerely hoped that from this WHO regional strategy, we can work towards estab-lishing a framework for traditional medicine in this region.

This conference is indeed a timely and appropriate platform, with the objectives of sharing and exchanging information on tra-ditional medicine amongst ASEAN member states; formulating a model of integration between traditional and modern medicine; updating the status of development on tra-ditional medicine standards and regulations in ASEAN member states as well as promot-ing GLOBinMED (Global Information Hub On Integrated Medicine) in ASEAN member states.

These are indeed challenging, but exciting, times for the further development of tradi-tional medicine for us in ASEAN.

For their untiring efforts to ensure the suc-cess of this significant event, I would like to take this opportunity to express my sincere ap-preciation to the ASEAN secretariat, ASEAN countries, local governments and agencies as well as the Nippon Foundation.

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5 1-15 February 2013 Medica l Br ie fs

To improve health literacy and empow-er senior citizens to make healthier choices, Singapore’s Health Promo-

tion Board (HPB) has developed and piloted a new program in the Choa Chu Kang com-munity.

The ‘Back to School’ program incorporates classroom workshops, hands-on and experi-ential educational activities to help residents and their caregivers understand, for exam-ple, the importance of home safety, good oral health and flu vaccination. It also provides se-nior citizens access to dental and functional screening services, and vaccination for influ-enza.

Singapore HPB takes senior citizens ‘back to school’

Singapore President Dr. Tony Tan re-cently launched the Centre for Innova-tion (CFI) and Changi Simulation Insti-

tute (CSI) – two new initiatives by the Eastern Health Alliance to meet healthcare challenges arising from an ageing population and growth in chronic diseases.

The CFI will provide a platform and re-sources for generating ideas, prototyping them and creating partnerships for health-care innovations, while CSI will provide rel-evant medical simulation training for teams of doctors, nurses and allied health profes-sionals.

New initiatives by Singapore’s Eastern Health Alliance

The program, jointly implemented by HPB and Choa Chu Kang Grassroots Organization and the South View Primary School, will be expanded to more constituencies next year.

Minister for Health and MP for Choa Chu Kang GRC, Gan Kim Yong, said the project is innovative and meaningful and will greatly benefit Choa Chua Kang residents.

HPB’s chief executive officer, Ang Hak Seng, said there is a low level of flu vaccine uptake among the elderly, with only one in 10 resi-dents aged 50 to 69 vaccinated in 2011. “The program not only allows them to be healthy, but to receive flu vaccine and get routine den-tal checks under one roof.”

Located alongside Changi General Hospi-tal’s training center, the facilities are open to the members of the alliance and other health-care partners, and will drive healthcare in-novation and clinical competencies, respec-tively.

The alliance will also join A*STAR’s ongo-ing collaboration with the Center for the Inte-gration of Medicine and Innovative Technolo-gy (CIMIT) in Boston, Massachusetts, US. This will allow it to benefit from CIMIT’s expertise in developing medical technologies and solu-tions, as well as from A*STAR’s science and engineering research capabilities.

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7 Malaysia Focus1-15 February 2013

To achieve the Millennium Development Goals by 2015, infant mortality has to be re-duced by two-thirds, and immunizing young children may contribute up to a 25 percent mortality reduction, Musa said.

“The consequences of this disease are dire, but are completely avoidable. Effective pre-vention methods need to be accessible to all children of Malaysia. It is important that edu-cation about preventive methods, are made available to all people of Malaysia and not just to those who can afford it,” he added.

A study estimated that approximately half of the effectiveness of current vaccines in preventing disease is associated with the altering of human-to-human transmission dynamics of the pathogens at upper respi-ratory mucosal surfaces, leading to herd immunity. [Trans Am Clin Climatol Assoc 2011;122:115-23]

Recognizing the herd effect benefitsof pneumococcal vaccination

Leonard Yap

Governments are quick to count the cost of vaccinating children against pneumococcal infections, but the

benefits of vaccination go far beyond protect-ing the child, says an expert.

A US study on the effects of mass vacci-nation of infants against pneumococcal se-rotypes showed a significant reduction in the rate of infection in adults above the age of 65, said Dato’ Dr. Musa Mohd Nordin, founding member of the Asian Strategic Al-liance for Pneumococcal Disease Prevention (ASAP) and a consultant pediatrician. [JAMA 2005;294(16):2043-51]

The study found a 73 percent reduction in infections in this older age group, from 33.6 cases per 100,000 people to 9 cases per 100,000 over a period of 7 years, Musa said. Studies have also shown that pneumococ-cal disease in older children and adults de-clined markedly after the introduction of vaccines for young children in 2000. [Vac-cine 2007;25(29):5390-8, MMWR Morb Mortal Wkly Rep 2008;57(6):144-8]

Musa called for political leadership and action to combat pneumococcal disease, pre-venting unnecessary suffering, economic hardship and possibly death. With the evi-dence pointing to the benefits of immuniz-ing the young on older populations, the cost should no longer be the reason behind the non-implementation of the pneumococcal vaccine, he said.


The immunological basis for herd immu-nity granted through vaccines is not well un-derstood. Mucosal immunoglobulins and/or serum IgG may interfere with bacterial acqui-sition has been proposed as a possible mecha-nism. [J Clin Invest 2009;119(7):1899-909]

Recent interest has focused on the concept of Th17 immunity by CD4+ cells expressing IL-17 and recruiting macrophages or neutrophils to eliminate or control colonization of patho-gens at mucosal sites. A study has shown mac-rophages mediating CD4+ Th17-dependent clearance of pneumococcal colonization in a mouse model. [J Clin Invest 2009;119(7):1899-909, Vaccine 2007;25S:A97–100]

Common manifestations of pneumococcal disease are otitis media, pneumonia, bactere-

mia and meningitis. Pneumococcal disease is caused by the bacteria Streptococcus pneumo-nia, also known as pneumococcus.

Pneumococcal disease is prevalent in Asia, but is often under-recognized. In Malaysia, pneumonia is the sixth larg-est cause of death. [Int J Antimicrob Agents 2011;38(2):108-17] The WHO has estimated that pneumococcal disease kills approxi-mately one million children younger than 5 years every year. Globally, the annual inci-dence is estimated at 14.5 million episodes of serious pneumococcal disease in children younger than 5 years. [Bull World Health Organ 2008;86:81-160, MMWR Morb Mortal Wkly Rep 2006;55(18):511-5, Wkly Epidemiol Rec 2007;82(12):93-104]

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Asian web portal on spinal cord rehabilitation launched during ASCoN

Pank Jit Sin

An online resource offering free mod-ules on managing spinal cord injury management is now available.

The website, accessible at www.elearnSCI.org, was launched during the Asian Spinal Cord Network (ASCoN) Conference. It fea-tures courses for all healthcare professionals and those associated with spinal cord injury (SCI) care. The seven modules include those for nurses; physiotherapists; occupational therapists and assistive technologists; psy-chologists, peer workers and counselors; and a module on SCI prevention.

The website is the brainchild of The Inter-national Spinal Cord Society (ISCOS), which saw the need for an avenue to disseminate knowledge and improve the quality of life of people living with SCI. Surveys conducted out on the availability of educational resourc-es for SCI in South Asia and some developed countries echoed the perceived inadequacy of material for care providers and those seeking further information on SCI. The website also reinforces the belief that life for patients with SCI can be happy and meaningful with prop-er care and support.

Dr. Harvinder Singh Chhabra, chief of spine service and medical director, Indian Spinal Injuries Centre (ISIC), said the mod-

ules were carefully selected to be as inclusive as possible, as care providers for those with SCI come from all walks of life and not just doctors and nurses.

Harvinder said input from experts from all over the globe has “ensured that the informa-tion available is applicable globally, irrespec-tive of the socioeconomic and cultural back-ground of the region.” The website is unique in being the first such educational resource available globally and totally free.

Predominantly funded by Access to Healthcare, which is a partnership program by Coloplast, the website is the result of a global collaboration between 332 experts from 33 countries. These experts came from organi-zations such as Livability, ISIC, the Lifetime Care and Support Scheme and ASCoN.

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Lee said there are several problems relat-ing to the use of testosterone replacement therapy. Firstly, there are ongoing debates among international organizations on what is considered the normal testosterone threshold. This complicates data from studies, as varying thresholds are considered normal. Threshold levels can also change with advancing age. Secondly, the lack of strict criteria complicates diagnosis. Current screening questionnaires like the Aging Male Symptoms (AMS) score and the St Louis ADAM questionnaire lack specificity. [J Men’s Health 2008;5(4):297-302]

Thirdly, testosterone assays vary in repro-ducibility and reliability. This introduces vari-ables into data collected in studies. Lastly, the challenge lies with the hormone itself. The ideal form of testosterone that should be mea-sured is free testosterone, or bioavailable tes-tosterone. [BJU International 2002;89:526-30 , Urologe A 2004;43:1069-75] However, free tes-tosterone levels are challenging to measure.

Use caution with testosterone therapy in patients with LOH

Malvinderjit Kaur Dhillon

Testosterone replacement therapy can be recommended for patients suffering from late-onset hypogonadism (LOH),

but this should be done in combination with regular monitoring and a lot of caution, says an expert.

“I would really like to help them [men who have LOH]. However, I have to do it respon-sibly, since testosterone replacement therapy is associated with several complications. In the past, prostate cancer was a major concern. We know that in men with prostate cancer, re-moving testosterone by castrating them will cause them to go into regression. But this is now seen to be a temporary phenomenon as prostate cancer will grow again because the cells learn how to be completely androgen in-dependent,” said Dr. George Lee, a consultant urologist.

“Immediately linking high testosterone levels with prostate cancer is an old mentality. More studies are beginning to show that men who are hypogonadal are more susceptible to prostate cancer, but men who have been re-ceiving testosterone for a very long time do not have an increased risk of prostate cancer. With this data, I am now more comfortable giving men who have been rendered impotent or are hypogonadal as a result of treatment of prostate cancer with radiotherapy or luteiniz-ing hormone releasing hormone (LHRH) ago-nists a little supplement in order to help them when their disease has stabilized,” said Lee.


Thus, studies tend to measure total testoster-one levels, including testosterone, which is bound to the sex hormone globulin.

Lee told Medical Tribune in a recent in-terview that there are still many grey areas connected to the subject. “[Knowledge of] men’s health is lacking compared to women’s health. Women’s health is well studied and documented. Technically speaking, we are still in the 60’s when it comes to LOH. Women have an advantage when it comes to studies as there is a clear-cut menopause diagnosis – their menses will stop. Since men do not have an age cut-off, we are learning a lot more about LOH and our understanding will con-tinue to increase,” he said.

Amidst the controversy shrouding this treatment, studies have shown that testoster-one replacement therapy can provide a wide range of benefits, including improvement in libido, bone density, muscle mass, body com-position, mood, erythopoiesis and cognition. [N Engl J Med 2004;350(5):482-92]

Lee encourages clinicians to treat men based on the symptoms and to not be fixated

with the figures. They should try to identi-fy the symptoms complex and if any of the symptoms are associated with an impaired QOL, such as a decrease in libido and if it affects their relationships; lack of concen-tration and if it affects their work; and in-creased grumpiness and if it impacts their family dynamics. If they present with any of these symptoms, they should be treated ac-cordingly.

Lee’s default approach is to encourage patients to alter their lifestyles. “After be-ing diagnosed with low testosterone, I will probably ask patients to start thinking about what they eat, if they exercise and advise them to improve on it. I will also see if they have truncal obesity, as well as measure their fasting glucose and fasting cholesterol in or-der to identify if these are correctable param-eters. A large number of patients see a slow increase in testosterone levels when their metabolic syndrome is corrected in a natu-ral manner. For patients who are unable or unwilling to correct the parameters, we then start thinking about testosterone replace-ment therapy.”


Pank Jit Sin

The use of modern technology can mini-mize the handling of embryos, while improving the monitoring capacity of

laboratory technicians.

Monitoring is extremely important in the in vitro fertilization (IVF) method of assisted reproduction. Traditionally, fertilized em-bryos are taken out of storage containers to be monitored by embryologists twice a day to determine their viability and suitability for transfer into the uterus. This method involves frequent handling of the embryos and yet only allows the embryologist to observe the embryos for a short period of time.

By using video capture and monitoring technology, embryologists now have access to continuous information throughout the em-bryos’ development, from fertilization until the stage where it is most suited for transfer.

Reduced handling, better monitoring of embryos can improve pregnancy rates

By looking at each embryo’s development through time-lapse video captures, seemingly good-quality blastocysts can be compared for their cleavage rates, cleavage intervals, cleav-age pattern and blastulation. Embryos that undergo fragmentation during development and subsequently reabsorbed can be disre-garded in the final consideration to be trans-ferred.

Transferring the best quality embryos will also lead to a reduction in multiple births (due to multiple embryo transfers) as only the healthiest single embryo with the highest chance of implantation and proper develop-ment will be transferred.

According to Gabor Bodis in his discourse with Medical Tribune, other benefits of single embryo transfer include higher mean ges-tational age and mean birth weight; lower rates of prematurity which can lead to very or extremely low birth-weight infants; and, therefore, lower instances of diseases such as respiratory distress syndrome, necrotiz-ing enterocolitis, anemia and pneumonia or sepsis – all of which are commonly associated with premature babies. Bodis is sales manager of Cryo Management Ltd, a company special-izing in devices used in assisted reproductive technologies.

‘‘... other benefits of single embryo transfer include higher mean gestational

age and mean birth weight


Balanced diet essential for optimal growth in toddlers

Saras Ramiya

Parents’ concerns with their child’s nu-tritional needs during ages 1 to 3 years are valid as nutrition in early childhood

has a profound impact on a child’s long-term development.

Children grow at a phenomenal rate, and the right nutrition is essential to ensure opti-mum physical growth; cognitive and visual development; bone and digestive health; and immunity. Studies on early childhood nutri-tion reveal that a balanced diet with the cor-rect combination of nutrients such as docosa-hexaenoic acid (DHA), arachidonic acid (AA) and lutein is important to support the physical growth and cognitive development of a child.

“DHA and AA, the biggest component of fat in the brain when combined, are polyun-saturated fatty acids that help in the cogni-tive function of the child and allow the child to develop better,” said Dr. Azam Mohd Nor, a consultant pediatrician and pediatric cardi-ologist.

Azam said AA and DHA have to be in an appropriate ratio as DHA is anti-inflamma-tory, while AA is pro-inflammatory. Exces-sive intake of DHA can lead to a reduction in AA levels in plasma and red blood cells. The

Food and Agriculture Organization (FAO) recommends that polyunsaturated fatty ac-ids (such as DHA and AA) make up no more than 11 percent of a child’s total energy in-take. [www.fao.org/docrep/013/i1953e/i1953e00.pdf Accessed on 22 January]

Another key nutrient, lutein plays an im-portant role in protecting the eyes by filter-ing blue light, which can damage the macu-la. Lutein is also an antioxidant that reduces oxidative injuries to the eye by neutralizing free radicals. [Am J Epidemiol 2001;153:424-32, Nutrition 2003;19:21-4]

Azam was speaking at the launch of Wy-eth Nutrition’s S-26 Classic Range for children aged 1 to 3 years.

Polyunsaturated fatty acids are crucial in the development of cognitive function in toddlers.

16 1-15 February 2013 Conference Coverage

with a mean age of 77 years was studied with a follow-up assessment at 3 and 6 months af-ter hip fracture surgery. Follow-up was done through telephone interviews.

The study results revealed that only 17.6 percent of patients regained their prefracture ambulation status after 3 months, while only 23.5 percent did so after 6 months. According to Lim, the remaining patients lost some degree of their ambulatory ability after internal fixation.

The 63rd Annual Convention of the Philippine Orthopaedic Association, 14-17 November, Crowne Plaza Hotel

Elderly unable to regain prefracture ambulation after surgery

Dr. Arla Carasco

A study by Dr. Chauncey Kester Lim, et al reveals that a majority of elderly patients in St. Luke’s Medical Center

with hip fractures who underwent internal fixation are not able to achieve their prefrac-ture ambulatory ability.

“Fractures of the hip are relatively com-mon in the elderly and often lead to devas-tating consequences,” Lim explained. He be-lieved them to be a major source of morbidity and mortality in the elderly.

The aim of his study was to determine if el-derly patients with hip fractures treated with internal fixation would be able to regain their prefracture ambulatory ability.

The study population included 34 patients admitted for femoral neck or intertrochanter-ic hip fracture due to trauma treated with in-ternal fixation from August 2010 to May 2011 who were 65 years old and above, ambulatory and cognitively intact.

Lim classified prefracture and postfracture ambulation based on the standard definitions of community and household ambulators. He also identified several predictor variables such as age, gender, pre-injury morbid con-ditions, prefracture ambulatory ability, post-fracture ambulatory ability at 3 and 6 months, and the type of fracture and fracture fixations. Ambulatory ability of the 34 geriatric patients

17 1-15 February 2013 Conference Coverage“For the predictors of decline of ambulato-

ry ability at 3 and 6 months (after hip fracture surgery), of all the predictors, only the pres-ence of comorbidity was noted to be of signifi-cance,” Lim said.

However, he revealed that one of the lim-itations of his study is that he was not able to perform physical examination and radio-graphic evaluation on the patients since the method used in the study was telephone in-terviews. This was mainly because the study focused on prefracture ambulatory ability and predictors of decline in ambulatory ability.

The study concluded that a majority of pa-tients with hip fractures who underwent in-ternal fixation were not able to achieve their prefracture ambulatory ability and, instead, suffered some degree of loss of their ambu-latory levels. Lim said the findings may be helpful in informing patients regarding the possible outcome of these types of fixations, especially among the elderly population.

Lastly, Lim recommended conducting fur-ther studies to compare the outcomes of dif-ferent fixation types such as internal fixation and replacement procedures.

18 1-15 February 2013 Conference Coverage

Fracture treatment protocol includes latest biodegradable antibiotic

The 63rd Annual Convention of the Philippine Orthopaedic Association, 14-17 November, Crowne Plaza Hotel

Dr. Nicolo Cabrera

A biodegradable local antibiotic deliv-ery system BonyPid™ has been incor-porated into a treatment protocol for

16 cases of Gustilo type III open fractures at the Philippine Orthopedic Center, reports Dr. Ruperto Estrada.

According to Estrada, previous attempts to incorporate local antibiotic therapy in open fracture management were disadvantaged by the need for subsequent surgical bead remov-al. Biodegradable delivery systems eliminate the need for follow-up surgery. Among the biodegradable delivery products in the mar-ket, BonyPid™ stands out as the only one that reports good control of release, an adequate duration of release, good osteoconductivity and adequate protection of the drug reservoir from hydration.

Estrada recruited 14 males and two females with open fractures of the diaphysis of the tib-ia, 11 of whom had Gustilo type IIIA fractures and five had IIIB. For inclusion, all patients had to have suffered injury between eight hours and 6 days prior to initiation of treatment. The patients were between ages 21 and 55 years, with an average age of 31.1 years.

All patients underwent debridement and irrigation, external fixation, 5 days of systemic antibiotics and BonyPid™ implantation. On repeat debridement after 2 to 6 days, initial BonyPid™ implants were removed and re-placed with fresh implants. The patients were

followed up on the 21st day, 4th week and 8th week.

Seven of the patients developed nosocomial infections. Four patients were infected with Pseudomonas aeruginosa, Burkholderia cepacia, Citrobacter freundii and Enterobacter aerogenes. Elevations in prothrombin times, SGOT, SGPT and total CPK were also noted.

Estrada concluded that no serious adverse events that developed in the course of the pro-tocol could be directly related to BonyPid™ use. He added that the implant could prevent or minimize bone infection following an open fracture.

“Because open type III fractures infect up to 30 percent of the time even with optimum standard of care, we hope that BonyPid™ will prove itself in further studies … and be of tre-mendous help in the treatment of infected open fractures,” Estrada closed.

BonyPid™ contains doxycycline, an anti-biotic active against both methicillin-sensitive and -resistant Staphylococcus aureus with a minimum inhibitory concentration (MIC) of 0.1 mcg/mL. An implant of one vial releases an initial 30 percent and subsequently 5 to 10 MIC/hour for three to four weeks, the length of time the body requires to heal the injury.

The polylactic-DL-glycolic acid (PLGA) polymer in BonyPid™ is FDA-approved and biocompatible, and is converted to lactic and glycolic acids in the body. The beta-tricalci-um phosphate included in BonyPid™ is em-ployed as a bone void filler.

19 1-15 February 2013 Conference CoverageThe 63rd Annual Convention of the Philippine Orthopaedic Association, 14-17 November, Crowne Plaza Hotel

Expert reports on hand osteoarthritis updatesDr. Carol Tan

Osteoarthritis is one of the most com-mon joint disorders globally, with the highest prevalence among the elderly

population, according to Dr. Emmanuel Es-trella, consultant with the department of or-thopedics in the Philippine General Hospital.

“In comparison with other osteoarthriti-des, the hand is the most commonly affected area. Seventy-five percent of [these patients] present with radiologic evidence of osteoar-thritis,” said Estrella.

The prevalence of hand osteoarthritis de-pends on the population studied and the di-agnostic criteria used- radiographic or clini-cal. The Rotterdam study reported that the prevalence of radiographic hand osteoar-thritis was 67 percent in women and 55 per-cent in men. [Ann Rheum Dis 2005;64:99-104] In contrast, the prevalence of symptomatic hand osteoarthritis, defined as hand pain and impaired hand function by the Ameri-can College of Rheumatology, was signifi-cantly lower. The prevalence of symptomatic hand osteoarthritis in the general population ranged from 2.0 to 6.2 percent. [Am J Phys Med Rehabil 2007;86(1):12-21]

Estrella said there is currently no conclu-sive evidence correlating radiographic signs of hand osteoarthritis with the presence and severity of hand symptoms.

Risk factors for hand osteoarthritis can be classified as intrinsic, environmental and pathologic. Intrinsic factors include age, sex, genetics, ethnicity, weight, grip strength and articular hypermobility.

Advanced age is the most important risk factor, and has been shown to be associated with increased disease prevalence and sever-ity.

Women are also at increased risk for hand osteoarthritis. A meta-analysis showed that the male sex was protective for hand osteo-arthritis, with a relative risk of 0.89 (95% CI 0.73 to 0.9). [OsteoArthritis and Cartilage 2005 ;13:769e781]

The involvement of chromosome 2 and 19 in the development of hand osteoarthri-tis were postulated in some studies. Ethnic-ity was also discovered to play a role, with a lower prevalence of hand osteoarthritis among the Chinese compared to Cauca-sian cohorts. [Osteoarthritis Cartilage 2007; 15:624-9] Grip strength and articular hyper-mobility were also shown to have a positive association with hand osteoarthritis in some studies.

Environmental risk factors include joint overuse, pneumatic vibratory tool use, pre-cision gripping and cold climate. Pathologic risk factors that were presented include in-creased bone mineral density and pseudog-out. However, studies still have conflicting re-sults as to the strength of association of these risk factors.

“Hand osteoarthritis is a prevalent condi-tion with a wide spectrum of presentation. … There is an absence of evidence linking hand osteoarthritis with most of the risk factors that were presented,” concluded Estrella. Further epidemiologic studies are still needed to bet-ter elucidate the risk factors of hand osteoar-thritis, he concluded.

20 1-15 February 2013 Conference CoverageThe 63rd Annual Convention of the Philippine Orthopaedic Association, 14-17 November, Crowne Plaza Hotel

Compression hip screw fixation treats fractures

Dr. James Salisi

Compression hip screw fixation with a tip to apex distance of less than 50 mm can successfully treat intertrochan-

teric and basicervical hip fractures accord-ing to a study conducted by Dr. Jonathan Ace Ras and Dr. William Lavadia at the St. Luke’s Medical Center Institute of Orthopedics and Sports Medicine.

The average tip to apex distance of the 32 patients included in the study was 47.97 mm with a range of 20 to 100 mm. Twenty-two of the patients (68.75 percent) showed intact implants with no evidence of back-out, cutout and other derangements on their follow-up radiographs compared to those done immediately after the opera-tion.

Four out of the 32 (12.5 percent) showed evidence of screw backout with an average deviation of 6 mm from original measure-ment taken immediately after surgery. Screw backout happened at different times for these patients, with one each happening at 1, 2 and 3 months after surgery.

Only one patient had a documented screw cutout, which showed at the second month of follow-up and whose tip to apex distance was measured at 30 mm.

The tip to apex distance is a measure of fixation of the implant in relation to the fem-oral head and determines the rate of failure or screw cutout. It is determined by getting the sum of the distance from the tip of the lag screw to the apex of the femoral head on anteroposterior radiograph and the same dis-tance on a lateral radiograph.

Researchers included 32 patients regard-less of age in the study. Twenty-four had intertrochanteric fracture and the rest had basicervical femoral neck fracture. The docu-mented follow-up ranged from 1 month to 15 months. Five were lost to follow-up, or those with no subsequent radiographs other than those done immediately after surgery.

The investigators correlated the radiologic profile of patients from January 1, 2009 to June 30, 2011 who underwent compression hip screw fixation with the incidences of complica-tions to determine the appropriate tip to apex distance. They reviewed the immediate post-operative radiographs of these patients and noted changes in the course of their follow-up, such as bone healing and evidence of implant cutout, backout and other derangements.

The investigators recommended other measures like ambulation status of the patient after surgery, bigger sample size and longer study duration for future studies.

22 1-15 February 2013 Regional

to reblockage at either the same or different sites. As a result, their arterial walls end up becoming rigid in many places due to mul-tiple metal stents left behind, explained Smits.

Absorb leaves behind only two pairs of tiny metallic markers which help guide its placement and remain in the artery to enable the physician to subsequently see where the device was placed.

As a result, the vessel can expand and con-tract as needed to increase the flow of blood to the heart in response to activities such as exercise. The need for long-term treatment with anti-clotting medications may also be reduced and any subsequent interventions would be unobstructed, Smits added.

Initial data from multiple ongoing studies in more than 20 countries around the world, indicate that Absorb performs similar to a best-in-class drug-eluting stent across tradi-tional measures such as major adverse cardio-vascular events and target lesion revascular-ization, according to Abbott Vascular.

Absorb is now available in Europe, the Middle East, parts of the Asia-Pacific region including Hong Kong, Malaysia and New Zealand, and parts of Latin America.

World’s first dissolvable drug-eluting stent

Absorb®, a drug-eluting stent made from polylactide, a naturally dissolv-able material.

Rajesh Kumar

The world’s first drug-eluting bioresorb-able stent promises to revolutionize the care for patients with coronary artery

disease (CAD).

Absorb® is made from a naturally dissolv-able material called polylactide that is com-monly used in dissolving sutures and is coated with the anti-proliferative drug everolimus.

It works by restoring blood flow in the blocked coronary artery similar to a metal-lic drug-eluting stent, but then dissolves into water and carbon dioxide within a few months, leaving behind a treated vessel that may resume its natural elasticity and pulsat-ing movement.

The device is being referred to as scaffold rather than stent to indicate its temporary na-ture and is creating quite a stir amongst inter-ventional cardiologists.

“There have been three significant mile-stones in the treatment of CAD in the last few decades – angioplasty, bare metal stents and drug-eluting stents. The fourth and lat-est revolution has been initiated with the in-troduction of Absorb … it has the potential to transform the way we treat patients,” said Dr. Pieter Cornelis Smits, director of interven-tional cardiology at Maasstad Ziekenhuis in Rotterdam, the Netherlands.

“With Absorb, the vessel may return to a more natural state over time, which could provide patients with important clinical ben-efits over the long-term.”

A stent is usually not required after about 6 months of treatment, when the artery gets un-blocked and can stay open on its own. Some patients may require repeat stenting due


sea and vomiting, joint pain with or without swelling, rash and low back pain. Currently, there is no vaccine or specific treatment for chikungunya infection. Treatment is primar-ily focused at relieving symptoms “which can drag on for months, or even years.”

“We have shown that shRNA antiviral tech-nology was effective in inhibiting the virus. It’s even highly specific for chikungunya,” Chu said. “We’re looking at it as a possible prophy-lactic treatment to reduce cases of infection.”

Unlike vaccines which provide long-term protection, the approach only gives short-term protection. However, it can be useful during an outbreak, similar to what Singapore ex-perienced between 2008 and 2010 where “we had close to 1,000 chikungunya cases.”

The study was funded by the Agency for Science, Technology and Research’s (A*STAR) Biomedical Research Council. Chu’s team is now working to translate their study results into clinical applications.

Singapore researchers knock down chikungunya

Principal investigator Dr. Chu Jang Hann (center), lab executive Chen Huixin (left) and lead researcher Shirley Lam (right) examine an X-ray film of chikungunya virus protein expression profile.

Elvira Manzano

Researchers from the National Univer-sity of Singapore’s (NUS) Yong Loo Lin School of Medicine have identified

a new gene silencing approach that can kill the chikungunya virus quickly, making pro-phylactic therapy possible for patients with this condition.

By employing small hairpin RNA (shRNA) technology directed against two specific chi-kungunya virus genes, E1 and nsP1, Ms. Shir-ley Lam, a postgraduate student from NUS and her team, were able to show that the strat-egy knocked down the virus and suppressed replication in infected cells within 3 days.

The approach, tested in both human cells and mice models, was able to protect the cells for up to 15 days, said Lam, who received the Singapore Young Scientist Award at the recent Singapore Health and Biomedical Congress for her work. “Our findings reinforce the potential usefulness of shRNA technology in clinical set-tings of chikungunya virus infection.”

Chikungunya shares some clinical symp-toms with dengue. “You really need a good diagnostic lab component to come into a play,” said principal investigator Assistant Professor Justin Hang-Hann Chu, of the Department of Microbiology, NUS Yong Loo Lin School of Medicine. “A PCR [polymerase chain reaction] is sensitive enough to tell the difference.”

Patients with chikungunya present with a sudden onset of fever, chills, headache, nau-


Nine-year-old CKD patient plays scientist

Radha Chitale

Despite having chronic kidney dis-ease (CKD) for the majority of her life, 9-year-old Meenakshi Sundaram

Losheni has not felt deterred from laboratories.

On the contrary, science is her favourite subject and she recently donned a lab coat to join scientists at Singapore’s Institute of Bio-engineering and Nanotechnology (IBN) to participate in their research for a day.

“Our researchers are developing next-gen-eration technologies for organ replacement and regenerative medicine, and volunteer op-portunities such as this inspire them by put-ting a face to the biomedical problems that they are working on,” said Professor Jackie Y. Ying, IBN executive director.

People with CKD progressively and ir-reversibly lose kidney function. As a result, waste builds up in the kidneys, leading to fa-tigue, low appetite, high blood pressure and, nerve and blood vessel damage. Losheni re-ceives hours of dialysis each night, in addi-tion to medication every day.

In adults, diabetes and high blood pressure are the primary causes of CKD, but children may get the disease as a result of a number of afflictions such as obstructive urology and kidney cysts. Children are commonly affected from ages 2 to 5.

In patients with CKD, progression to end stage renal disease (ESRD) is inevitable and kidney transplants are required. About 70 percent of children with CKD will develop ESRD by age 20; the 10-year survival rate is 80 percent. Death occurs most often due to car-diovascular disease and infection.

IBN partnered with the Make-A-Wish Foundation® Singapore to bring Losheni to their facility in Biopolis. She was able to examine stem cells from liver, bone and kidney that might be used in tissue engi-neering and present her findings to the lab group.

Mr. Paul Heng, board chair of the Make-a-Wish Foundation® Singapore, said he hoped that the experience, aside from fulfilling Losh-eni’s intellectual curiosity, would prepare her for her own kidney transplant.


on routine clinical samples that clinicians can feel comfortable using to allocate treatment.

“At the end of the day, we want the clini-cian to take the information and act on it,” he said.

The immediate impact on patients would be validated biomarker assays that quickly identify subgroups of patients who will re-spond to available therapies.

POLARIS initiative hones in on personalized medicine

The S$20 million initiative aims to deliver specialized therapies to patients who need them

Radha Chitale

A S$20 million initiative by Singapor-ean research institutes and hospitals to link biomarker technology and

clinical practice could help deliver specialized therapies to patients who need them.

The POLARIS initiative will capitalize on existing genomic and metabolomic research in Singapore, particularly in diseases which have a large burden or a different presenta-tion in Asian populations, based on the prin-ciples of stratified, or personalized, medicine.

“We want to transform disease manage-ment by moving away from a one-size-fits-all type of approach to targeting specific thera-pies to specific patient groups,” said program lead Dr. Patrick Tan, of the Genome Institute of Singapore at the Agency for Science, Tech-nology and Research (A*STAR).

“The challenge now lies in how to realize the clinical value of those initial [biomarker] discoveries. In order for that to happen, the technologies that we use to give rise to those discoveries must then be taken from the re-search center back into the clinics where these findings can be implemented in the form of certified clinical tests.”

Currently, there is no accredited facility to analyze biomarker assays in Singapore and patient samples must be sent overseas.

Tan said they hoped to set up a local facility, certified by the College of American Patholo-gists, to carry out standardized, robust testing

26 1-15 February 2013 RegionalA portion of patients do not respond to ex-

isting therapies. The current model for enroll-ing such patients in clinical trials to receive experimental therapies is time consuming and costly because assessing their eligibility is decentralized and requires multiple bio-marker assays. For example, a cancer patient at the National Cancer Centre Singapore must be evaluated several times to see if they are eligible for one of 40 to 50 ongoing clinical trials. During this time, disease can progress, Tan said.

Unresponsive patients who consent to participate in POLARIS would be evaluated once for biomarkers that match existing ex-perimental therapies in ongoing clinical tri-als, which reduces the time it takes for them to receive treatment.

Patients who remain unresponsive or who relapse may be evaluated further by whole genome sequencing and other types of bio-marker analysis for novel diagnostic or thera-peutic targets to be tested in clinical trials.

Pharmaceutical industry involvement to design clinical trials and develop new prod-ucts will be a key facet of POLARIS.

“It’s a more orchestrated system to en-hance discoveries and findings based upon patients so that you are capturing the maxi-mum amount of information from each pa-tient with the minimum cost and the most ef-ficiency,” Tan said.

Four institutes from A*STAR and clini-cians from Singapore General Hospital, the National Cancer Centre Singapore, Singapore National Eye Centre and the National Univer-sity Health System have partnered to be part of POLARIS.

At present, POLARIS will focus on lung and gastric cancers and eye diseases, both be-cause of the heavy local disease burden and because of the number of identified biomark-ers. However, the initiative is scalable to other diseases and research groups.

POLARIS is funded by a 3-year S$20 mil-lion grant from A*STAR’s Biomedical Re-search Council and represents the integration phase of Singapore’s initiative to grow the biomedical sciences sector.

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28 1-15 February 2013 Thrombosis Focus

Ticagrelor recommended for STEMI in latest ACC/AHA guidelinesRajesh Kumar

The American College of Cardiology (ACC) and the American Heart Asso-ciation (AHA) have updated their clini-

cal practice guidelines for the management of ST-elevation myocardial infarction (STEMI) to include a class I recommendation for the use oral antiplatelet medicine ticagrelor..

The guidelines recommend that reperfu-sion therapy be given in a timely manner to all eligible patients with STEMI undergoing either percutaneous coronary intervention (PCI) or fibrinolytic therapy. [J Am Coll Cardiol 2012; doi:10.1016/j.jacc.2012.11.019] They also suggest that patients who present to a non-PCI capable hospital should be considered for transfer either for primary PCI, or if anticipat-ed time to PCI is greater than 2 hours, after fibrinolysis.

Appropriate antithrombotic therapy, in-cluding dual antiplatelet and anticoagulant therapy (with clopidogrel, prasugrel or ti-cagrelor), should be used during and after re-perfusion therapy, a report on the guideline revisions added.

The recommendation on ‘Antiplatelet Ther-apy to Support Primary PCI for STEMI’ (4.4.1) suggested that aspirin at a dose of 162 to 325 mg should be given before primary PCI and should be continued indefinitely thereafter; while a loading dose of a P2Y12 receptor in-hibitor such as clopidogrel 600 mg, prasugrel 60 mg or ticagrelor 180 mg should be given as early as possible or at the time of primary PCI.

Thereafter, maintenance doses of clopido-grel 75 mg daily, prasugrel 10 mg daily or ti-cagrelor 90 mg twice a day should be given for 1 year to those receiving a bare metal or drug-eluting stent during primary PCI.

Prasugrel vs clopidogrel for ACS without revascularization

There is uncertainty about optimum platelet inhibition therapy for patients with unstable angina or non-ST-seg-

ment elevation myocardial infarction (non-STEMI) who are managed without revascular-ization. A study at 966 sites in 52 countries has shown similar results with either prasugrel or clopidogrel. [N Engl J Med 2012;367:1297-367]

A total of 7,243 patients aged <75 years were randomized to take either prasugrel 10 mg daily or clopidogrel 75 mg daily, in addi-tion to aspirin, for up to 30 months. After an average follow-up of 17 months the primary

endpoint (cardiovascular death, myocardial infarction or stroke) was reached by 13.9 percent (prasugrel) vs 16.0 percent (clopi-dogrel), a nonsignificant difference. Further analysis of multiple ischemic events sug-gested a lower risk with prasugrel (a signifi-cant 15 percent reduction). Heart failure was more frequent in the clopidogrel group. Oth-erwise, the rate of adverse events was similar in the two groups.

Prasugrel did not reduce the frequency of the primary endpoint significantly compared with clopidogrel.

29 1-15 February 2013 Drug Prof i le

Aspirin has been the cornerstone of ACS treatment for decades. Its action is mostly due to inactivation of platelet cyclooxygenase 1, which leads to the inhibition of thromboxane generation, and thus disrupts platelet aggre-gation. However, aspirin alone fails to pre-vent the majority of recurrent events and this has prompted investigations into alternative methods of blocking platelet action. [Postgrad Med J 2012;88:391-396]

At the molecular level, one of the critical components for platelet aggregation is the platelet P2Y12 receptor. Therefore, block-ade of the P2Y12 receptor is an important treatment strategy that is employed in con-junction with aspirin. The clinical benefits of dual antiplatelet treatment with aspirin plus clopidogrel in the management of ACS are well established. However, clopidogrel is a pro-drug that requires hepatic activa-tion and there are several concerns regard-ing its use.

Ticagrelor: Latest recommendations underline antiplatelet agent’s usefulness in ACSOral antiplatelet agent ticagrelor (Brilinta®, AstraZeneca) was recently given a class I recommendation in the latest revision of the American College of Cardiology (ACC) and American Heart Association (AHA) clinical practice guidelines for the management of patients with ST-elevation myocardial infarction (STEMI). The following article discusses the management of STEMI and other acute coronary syndromes (ACS), profiling the drug ticagrelor.

Naomi Adam, MSc (Med), Category 1 Accredited Education Provider (Royal Australian College of General Practitioners)

Antiplatelet agents for the management of ACS

Cardiovascular diseases remain the lead-ing cause of mortality worldwide and more than half of these deaths involve coronary artery disease with acute coronary syn-dromes (ACS). Variants include ACS with and without ST-segment elevation, such as unstable angina, non-ST elevation myocar-dial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI). [Postgrad Med J 2012;88:391-6]

The pathophysiology of all of these syn-dromes features the disruption of an ath-erosclerotic plaque that results in intra-coronary thrombogenesis. Platelets play a key role in both the development of ath-erosclerosis and subsequent thrombosis. In acute thrombosis there is a multiple-step mechanism that involves platelet adhesion, activation and aggregation at the site of in-jury, followed by cross-linking through fi-brin, ultimately leading to obstruction of the coronary vessel. Hence, medications that inhibit platelet action are a mainstay of therapy in this setting. [Curr Cardiol Rep 2012;14:457-67]

30 1-15 February 2013 Drug Prof i leThese include delayed onset of action,

variability in antiplatelet effects, prolonged recovery of platelet function after discon-tinuation and interactions with commonly used agents such as proton pump inhibitors. While the use of clopidogrel has been a ben-eficial advance in the treatment of ACS, its shortcomings have prompted investigations of alternative P2Y12 receptor antagonists. [Postgrad Med J 2012;88:391-6, Curr Cardiol Rep 2012;14:457-67]

TicagrelorTicagrelor is the first member of a new

class of antiplatelet agents – the cyclopentyl-triazolopyrimidines – to undergo clinical de-velopment. Its inhibitory effects on platelet function are mediated predominantly via the P2Y12 receptor. Ticagrelor provides more ef-fective inhibition of platelet function, with a faster onset and offset of action than clopido-grel. [Drugs 2011;71:909-33]

Pharmacokinetics and metabolismFollowing oral administration, ticagrelor is

rapidly absorbed and converted to its major metabolite – AR-C124910XX. Unlike clopido-grel, ticagrelor is itself an antagonist of the P2Y12 receptor. The pharmacokinetics of ti-cagrelor are linear with dose-proportional ex-posure up to doses of 1,260 mg. Peak plasma concentrations are reached at a median of 1.5 hours of administration and it has a mean half-life of 7 hours. The timing of a meal relative to a dose of ticagrelor has no appre-ciable effect on its pharmacokinetics. [Drugs 2011;71:909-933]

Metabolism of ticagrelor occurs predomi-nantly via CYP3A4 and CYP3A5. Elimina-tion of ticagrelor and AR-C124910XX occurs primarily via hepatic metabolism and biliary secretion, respectively. [Drugs 2011;71:909-33]

Clinical efficacyThe pivotal clinical trial of ticagrelor was

the Platelet Inhibition and Patient Outcomes (PLATO) study. This was a multicenter, double-blind, randomized trial that com-pared P2Y12 antagonists for the prevention of cardiovascular events on a background of aspirin therapy in 18,624 patients hospi-talised with ACS. Subjects were assigned to either ticagrelor (180 mg loading dose, 90 mg twice daily thereafter) or clopidogrel (300–600 mg loading dose, 75 mg daily there-after). The primary efficacy endpoint was the time to the first occurrence of composite of death from vascular causes, myocardial in-farction, or stroke. After 12 months of follow up, the primary endpoint occurred signifi-cantly less often in the ticagrelor group than in the clopidogrel group (in 9.8% of patients vs 11.7 percent; hazard ratio, 0.84; 95% CI 0.77–0.92; P<0.001). There was no difference in the overall major bleeding rate between the two groups, though ticagrelor was asso-ciated with a significant increase in the rate of non-procedure-related bleeding. [N Engl J Med 2009;361:1045-57]

Adverse effectsIn clinical trials, adverse events associated

with ticagrelor included ventricular pauses, dyspnea, hyperuricemia and increased cre-atinine. [Drugs 2011;71:909-33] Contraindica-tions according to the product label are active pathological bleeding, a history of intracranial hemorrhage and moderate-to-severe hepatic impairment. The label also states that ticagre-lor should be used with caution in patients at risk of bleeding (eg, recent trauma, surgery, GI bleeding, concomitant NSAIDs or fibrino-lytics). If a patient reports new, prolonged or worsened dyspnea, this should be investigat-ed fully and if not tolerated, treatment with ticagrelor should be stopped. [Brilinta Product Monograph. February 2012]

31 1-15 February 2013 Drug Prof i leThere is a potential for drug interactions

mediated by CYP3A4, hence co-administra-tion with strong inhibitors such as ketocon-azole, clarithromycin, nefazodone, ritonavir and atazanavir is contraindicated. [Drugs 2011;71:909-33, Brilinta Product Monograph. February 2012]

DosingThe approved dosage is as per that used in

the PLATO trial: treatment should be initiated with a loading dose of 180 mg ticagrelor (two tablets of 90 mg) and then continued at 90 mg twice a day for up to 12 months. Patients taking ticagrelor should also take low-dose aspirin daily, unless specifically contraindicated. Fol-lowing an initial loading dose of aspirin, the maintenance dose is 75–150 mg per day.

Guideline recommendations for ticagrelor The UK National Institute for Clinical Excel-

lence (NICE) has recommended that ticagrelor in combination with low-dose aspirin is rec-ommended for up to 12 months as a treatment option in adults ACS, including those with:

• ST-segment-elevation myocardial infarction (STEMI) – defined as ST elevation or new left bundle branch block on electrocardiogram – that cardiologists intend to treat with primary percutaneous coronary intervention (PCI)

• non-ST-segment-elevation myocardial infarction (NSTEMI) or admitted to hospital with unstable angina – defined as ST or T wave changes on electrocardiogram suggestive of ischemia.

The NICE recommendations further sug-gest that before ticagrelor is continued beyond the initial treatment, the diagnosis of unstable angina should first be confirmed, ideally by a cardiologist. [NICE technology appraisal guidance 236. www.nice.org.uk/ta236. Octo-ber 2011]

Subsequently, the American Heart Associa-tion (AHA) Task Force on Practice Guidelines and the American College of Cardiology Foun-dation (ACCF) have also updated their rec-ommendation to state that ticagrelor should be considered as an equal option to clopido-grel for patients with NSTEMI [Circulation 2012; 126: 875–910] and for STEMI [J Am Coll Cardiol 2012; doi:10.1016/j.jacc.2012.11.019].

Further long-term and comparative effi-cacy and tolerability data will be needed to definitively position ticagrelor with respect to other antiplatelet agents. However, the data so far indicate that ticagrelor is a promising option for the treatment of patients with ACS and may be of particular use in those at high risk of ischemic events or unresponsive to clopidogrel.

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33 1-15 February 2013 After Hours

Alan Sim

William Tay

serve up healthy gourmet on a tray

Radha Chitale

The kitchens at Mount Elizabeth Nove-na Hospital fire up at 5 each morning. Chefs at seven different stations begin

chopping vegetables, cooking rice, reviewing menus and making preparations for break-fast.

Executive Chef Alan Sim stops by each section every day to check a recipe or tweak a garnish. Each meal is calibrated to precise amounts of calories, fats, vitamins and miner-als and carefully vetted by dieticians.

With such a clinical approach, it is no won-der that “hospital food” is not usually asso-ciated with gastronomic heights; more along the lines of bland, wilting fare, to be endured like another hospital procedure.

But if patients don’t eat – because they have no appetite, because they don’t like the food being served – they are missing the nu-trition that is a critical part of care and recov-ery. Patients who eat the least tend to have the worst clinical outcomes and are at in-creased risk of malnutrition. [Nutr Clin Pract 2012;27:274-80]

Behind the scenes of many of Singapore’s hospitals, teams of chefs, nutritionists and di-eticians work to put together healthy menus that don’t compromise on flavor.

“We need to provide food that will change the entire perception of hospital food,” Sim said.

Know thy dishSim’s background is largely in hotel kitch-

ens, like many chefs who have found their way to the health care industry. They are no strang-ers to producing meals on a large scale. A large public hospital like Singapore General Hospi-tal (SGH) serves about 4,000 meals per day.

But cooking within rigid nutritional guide-lines can pose a challenge for chefs used to prioritizing flavor.

To help kitchen staff understand how to put together a balanced meal, hospital dieti-cians brief them on nutrition, dietary guide-lines, therapeutic diets for diabetic or cancer patients, for example, and how to use substi-tute ingredients based on patient needs.

For normal meals, hospitals follow the di-etary guidelines recommended by the Minis-try of Health. However, a diabetic patient will need meals that contain less sugar and more vegetables. A hypertensive patient will need meals low in salt. Meals may also need to be altered for vegetarian or Halal requirements.

“I have to be precise. I need to know what makes it into the ingredients and composition of a dish and also the nutrients that go into

34 1-15 February 2013 After Hours

that,” said Ms. Poh Leng, one of the dieticians who worked with Sim to develop the menu at Mount Elizabeth Novena. “That way, in case I need to modify the diet from the normal menu, I can. In a food that has a milk product, I might suggest a soy bean.”

Diabetic diets are the most common therapeutic diets offered in hospitals but kitchens can also offer meals that are low in fiber for colorectal surgery patients or low in iodine (no seafood or processed food) for patients on radioactive cancer treatment.

Research and developmentOnce the dietician has balanced the calories, fats, sugars, pro-

teins and other components of patient meals, the chefs can get busy in the kitchen – and this is where they need to be creative because their old flavor tools are no longer at their disposal.

“We seldom see butter,” Sim sighed. Also gone are sugars, coconut milk, fried foods, white rice, and

liberal sprinkles of salt. In their place: brown rice, yogurt, tofu and egg whites.

Some substitutions are easy – canola or olive oils instead of palm oil, for example, which is high in saturated fat.

Others modifications require more innovation. Khoo Teck Puat Hospital Executive Chef William Tay said he

reduces stocks to concentrate the natural flavor and cut down on added salt. Tamarind and yogurt can be subbed into curries for sea-soning instead of salt and coconut milk to reduce sodium and fat.

“I like to use some local herbs like lemongrass and pandan leaf for flavor, especially when cooking western style,” he added.

Cooking techniques can lighten a dish. Roasting, steaming, stir frying in less oil and sous vide are preferable to frying.

Another trick for sticking to a calorie count without compromis-ing taste is to manage portions.

“If you want to cook food that is suitable for every patient, change the portion size,” Tay said. “Good food is not always healthy but it depends on how you portion it.”

Looking good enough to eat Still, chicken rice served in a hospital won’t taste like the same

dish from a hawker stall. That is why presentation counts for a lot when serving hospital meals. Both Tay and Sim said they always try to impress patients visually.

35 1-15 February 2013 After Hours“My main concern is to ‘cook health, eat

healthy’... but we want to make people say ‘wow!” Tay said. “Instead of mixing all the food together, I’d rather do a garnish and a nice presentation.”

Ms Koay Saw Lan, senior manager of Food Services at SGH, said they use nicely designed crockery, tray liners, and clear food covers to make meals look good.

These visual cues can help revive ill pa-tients’ appetites and keep them on the path to recovery.

“What you want to look forward to is a new tray with a nice meal for you. Some-thing that’s appetizing and makes you want to eat,” said Ms. Beatrice Pung, chief dietician at Mount Elizabeth Hospital.

Hospitals get feedback on meals through patient rounds by kitchen staff and random surveys and incorporate their findings into future meal planning. Chefs and dieticians volley recipes back and forth to make sure each meal is nutritionally complete and tasty.

Unlike food in restaurants, meals in a hospital must contribute to healing and re-covery.

“Patients depend on us to supply the nu-trients in the right balance to augment the physician’s treatment,” Koay said. “The food supplied also serves as examples for them to comply with upon discharge. That is why we show and tell patients, especially those on therapeutic restrictions, how modifications can be made.”

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References: 1. W. Graf, Bacteriological Investigations with Salviathymol®. Das Deutsche Zahnartzeblatt XXIV, 4, 174-1792. M. Hunkirchen. Clinical results with Salviathymol® in the treatment of inflammatory conditions of the oral cavity. Das Ceutsche Zahnarzteblatt 1970, No. 3, Vol. 24 pp 3-15

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37 1-15 February 2013 In Pract ice

Managing shoulder pain

Dr. Eugene Wong Consultant Orthopedic & Spine Surgeon Adjunct Assistant Professor Perdana University Graduate School of Medicine Serdang, Selangor

Sti�ness

Weakness, lag signspainful arc anddrop-arm test

Tender AC jointRadiographs show

osteoarthritis

Inject AC joint,refer it pain recurs

Partial rotatorcu� tear

Physical therapySubacromial injection

Refer if no reliefin 3 months

Genohumeralosteoarthritis

Pain medicationsActivity modi�cation

Refer for jointreplacement

Normal

Adhesive capsulitis

Physical therapyprogram

for streatching

If no improvementafter 3 months,

refer to specialistfor glenohumeral

injection andpossible surgery

Obtain radiographs

Yes

Rotator cu� problem or Acromioclavicular(AC) joint osteoarthritis

No

Magnetic resonance imaging

Full-thicknessrotator cu� tear

Refer for repair

Yes

No tear:impingement

syndrome

Physical therapy

Subacromialinjection

Refer if noimprovementin 3 months

No

Treatment Algorithm for Shoulder Pain.

Sour

ce: C

leve C

lin J

Med

200

7;74

(7):4

73-4

, 477

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80-2

pas

sim.

Figure 1: Rotator cuff arthropathy.

Figure 2: Acromioclavicular joint arthritis.

Figure 3: Supraspinatus tendinopathy.

Figure 4: Supraspinatus full thickness tea.

Figure 5: Calcific tendonitis. Figure 6: Biceps tendonitis.

Figure 7: Shoulder arthritis. Figure 8: Adhesive capsulitis. Figure 9: Labral tear.

The shoulder is the most mobile and least stable joint. This predisposes it to a vari-ety of conditions. Shoulder pain is a com-

mon complaint in patients over the age of 40.The prevalence of shoulder pain is between

16 and 26 percent, and every year 1 percent of adults over the age of 45 years present with a new episode of shoulder pain. It is the third most common cause of musculoskeletal consul-tation in primary care. [BMJ 2005;331:1124-8]

The 1-month prevalence of shoulder pain is 16 percent. Fifty percent of new episodes of shoulder disorders recover within 6 months, rendering it a condition with likely long-term consequences. [Pain 2004;109:420-31]

Signs and symptomsThe clinician can determine where the pain

is arising from history and physical examina-tion. It could be from the acromioclavicular joint, glenohumeral joint or the rotator cuff. Pain in adhesive capsulitis tends to have a more gradual onset, and a traumatic rotator cuff tear causes pain immediately.

A common complaint of patients with any shoulder disorder is night pain, described by many as a steady ache that wakes them up in the middle of the night. History is elicited to find out if the symptoms are acute or an exac-erbation of a chronic condition. Stiffness may be associated with weakness and loss of mo-tion. There may be catching, crepitus, grind-ing and functional impairment.

Rotator cuff pain is a constant ache, which varies with activity. There may be night pain, which wakes up the patient. Pain radiating to the top of shoulder may

38 1-15 February 2013 In Pract icebe due to cervical spondylosis. Pain in the mid range of motion may be caused by arthritis or inflamed tissues. Pain at the end of the range of motion is due to impingement.

Acromioclavicular joint arthritis is pain on the top of the shoulder, whereas other shoul-der disorders can cause pain to radiate down to the middle of the arm. Rotator cuff tears and impingement syndrome cause pain on the front and side of the shoulder. Patients with arthritis have less specific areas of pain, as do patients with adhesive capsulitis.

The most common causes of shoulder pain in primary care are reported to be rotator cuff disorders, acromioclavicular joint disease and glenohumeral joint disorders. Eighty-five per-cent of shoulder pain arises from the shoul-der itself, with the remainder usually referred from the neck. [BMJ 2005;331:1124-8]

Overhead activities exacerbate pain in im-pingement syndrome and rotator cuff tears. Acromioclavicular joint arthritis causes pain when the arm is brought across the body. Ad-hesive capsulitis and arthritis cause pain with all motions of the shoulder, particularly when reaching behind the back or attempting to reach overhead.

DiagnosisAcute shoulder pain may be the first warn-

ing sign of serious disease. Although uncom-mon, the conditions in Table 3 should be con-sidered.

Anteroposterior and axillary lateral ra-diographs of the shoulder should be ob-tained if the patient has any loss of mo-tion to distinguish between osteoarthritis and adhesive capsulitis. Cyst formation in the greater tuberosity and superior migra-tion of the humeral head in relation to the glenoid are consistent with rotator cuff tears.

An ultrasound scan can be used to diag-nose tendon tears around the shoulder. Mag-netic resonance imaging (MRI) is commonly used to evaluate the shoulder because it can show abnormal areas of the soft tissues. MRI can diagnose rotator cuff tendon disorders, infection and tumors. An MRI scan should be obtained if the clinician suspects a rotator cuff tear or if the patient has persistent pain after a 3-month course of physical therapy.

An impingement test involves a subacromial injection of lidocaine 1 percent 10 cc and cortico-steroid. In the case of rotator cuff tear, the pain is relieved, but weakness persists. Pain is relieved and strength improves in the case of impinge-ment, tendinitis and bursitis. Pain persists and motion is unchanged in adhesive capsulitis or arthritis. Diagnostic and therapeutic injections can be administered into the subacromial bursa, acromioclavicular joint and glenohumeral joint.

TreatmentTreatment generally involves rest, altering

activities and physical therapy to help pa-tients improve shoulder strength and flexibil-ity. Commonsense solutions such as avoiding overexertion or overdoing activities which they normally do not participate in can help prevent shoulder pain.

Medications can reduce inflammation and pain. Injections of numbing medicines or ste-roids into the shoulder joint can relieve pain. Most patients with an acute injury will ben-efit from 2 to 3 days in a sling. However, pro-longed immobilization should be avoided as it can lead to frozen shoulder and contractures.

Shoulder stability and function can be en-hanced by practicing good posture, maintain-ing a balance of flexibility and strength in all shoulder muscles, and selecting appropriate exercises and performing them correctly.

39 1-15 February 2013 In Pract icePendular and wall climbing exercises, as well

as physical therapy, can be useful in improving shoulder range. Strengthening the muscles that support the shoulder will help keep the shoul-der joint stable. Keeping these muscles strong can relieve shoulder pain and prevent further injury. Stretching the muscles is important for restoring range of motion and preventing in-jury. Gently stretching after strengthening exer-cises can help reduce muscle soreness and keep muscles long and flexible.

Ninety percent of patients with shoulder pain will respond to simple treatment meth-ods such as altering activities, rest, exercise and medications. Surgery may be needed for recurring dislocations, infection, tumor and some rotator cuff tears.

Recovery from shoulder pain can be slow and recurrence rates are high, with 25 percent of those affected by shoulder pain reporting previ-ous episodes, and 50 percent reporting persist-ing pain or recurrence at 12-month follow-up.

Table 1: Causes of shoulder pain.Arising from the shoulder:• Rotator cuff disorders - tendinosis, full or partial thickness tears, calcific tendinitis.• Adhesive capsulitis• Glenohumeral osteoarthritis• Glenohumeral instability• Acromioclavicular joint pathology• Infection• Traumatic dislocationReferred pain:• Cervical pathology - degenerative disc disease• Chest wall pathology - costochondritis of upper ribs• Cardiac - myocardial ischemia, pericarditis• Pulmonary - pneumonia, pancoast tumor• Diaphragmatic irritation - perforated pep- tic ulcer

Table 2: Predisposing factors. • Work above shoulder height• Heavy workload• Low-frequency vibration• Repetitive work tasks• Driving for long periods• Shift work• Sleep disturbance• Smoking• Caffeine consumption

Table 3: Serious shoulder conditions.• Tumors • Inflammatory arthropathy - rheumatoid arthritis, gout and psoriatic arthropathy.• Visceral disease - any condition that irri- tates the mediastinal pleura, pericardium or diaphragm. • Myocardial ischemia• Septic arthritis• Fracture and dislocation - history of trauma and sudden onset of pain in osteopo- rotic patients.

Table 4: Clinical shoulder tests.• Rotator cuff tear• Painful arc• Empty can test• Drop sign• Lift off test• Impingement• Hawkin’s test• Instability• Relocation test• Augmented apprehension• Labral tear• Crank test• Active compression test• Acromioclavicular joint• Active compression test

40 Industry Update

Regulating fasting and postprandialglucose in T2DM patients with acombination drug

A combination of metformin, which predominantly lowers fasting glu-cose, and the GLP-1-like effect of sax-

agliptin, which lowers postprandial glucose, may be an efficacious solution in treating type 2 diabetes mellitus (T2DM), says an expert from the US.

“Saxagliptin (Onglyza®, AstraZeneca) is a DPP-4 inhibitor that has been on the mar-ket for a while now and acts primarily by re-ducing postprandial glucose. Metformin, on the other hand, is effective in lowering fast-ing glucose. It is logical, then, to think about combining saxagliptin with metformin so you get a lowering in both fasting and postpran-dial glucose. This combination is physiologi-cal as the DPP-4 inhibitor only acts to lower glucose levels when they are elevated,” said Professor Harold Lebovitz, professor of medi-cine, division of endocrinology and metabo-lism/diabetes, State University of New York Health Sciences Center. [Curr Med Res Opin 2009;25(10):2401-11, Diabetes 2000;49:2063-69]

Lebovitz said saxagliptin has the added advantage of being weight neutral. [Diabe-tes Obes Metab 2008;5:367-86] Studies have shown that the combination of saxagliptin and metformin (KombiglyzeTM XR, Astra-Zeneca) is also weight neutral and has a low hypoglycemic risk. [Ann Med 2012;44(2)157-69] This is in contrast with insulin therapy, which has known side effects of hypo-glycemia and weight gain. [N Engl J Med 2009;361(18):1736-47]

“This combination is a very nice approach to treating diabetes using the normal physio-logical pathways. It is promising as it restores how you handle a meal when you are fasting and minimizes your ability to have low blood sugar as well as weight gain,” said Lebovitz.

Metformin is a first-line drug of choice for the treatment of T2DM. However, a study published in Diabetes Care showed that out of 3,388 patients with T2DM who started on initial metformin monotherapy, only one-third achieved target HbA1c levels. [2010;33:501-6]

A study evaluating the efficacy and safety of initial combination of metformin and saxa-gliptin versus saxagliptin or metformin as monotherapy showed the combination ther-apy displayed significant statistical improve-ment across all key glycemic parameters com-pared to either treatment alone. [Diabetes Obes Metab 2009;11(6):611-22]

“Metformin may cause gastrointestinal side effects. [Am J Ther 2003;10(6):447-51] This

41 Industry Updateis the reason why metformin XR, a long-act-ing form of metformin, is used instead. Ordi-narily, patients would be required to consume metformin pills several times a day as taking the pills all at once may result in side effects. With the slow-release version of metformin, patients only have to consume one or two pills, depending on the dosage they require, in 24 hours,” said Lebovitz.

A study published in the Current Medi-cal Research and Opinion that looked at the gastrointestinal tolerability of extended-release metformin (metformin XR) tablets compared to immediate-release (metfor-min IR) tablets showed that patients who switched from metformin IR to metformin XR or patients who were initiated on met-formin XR experienced fewer gastrointesti-

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nal adverse events with comparable doses of metformin.

“When you are put on a medication that requires you to take it four times a day for 2 weeks, do you take it as instructed? No, you take it four times a day when you feel ter-rible, and when you feel better you take it three times a day or less. You don’t take it the way you’re supposed to. People are like that with every medication. The more medication they have to take, the less compliant they are. This medication takes advantage of two really good drugs in a form that is easy to consume, so patients will be relatively compliant,” he added. [Diabetes Metab 2003;29:79-81]

Lebovitz was speaking at the launch of Kombiglyze XR recently.

42 1-15 February 2013 Internat ional

MSF welcomes new TB drugSaras Ramiya

Médecins Sans Frontières/Doctors Without Borders (MSF) welcomes the approval of bedaquiline by the

US Food and Drug Administration on 31 De-cember 2012.

Bedaquiline is the first new drug active against tuberculosis (TB) to be registered since 1963.

“The first new drug to treat TB in 50 years is an immense milestone,” said Dr. Manica Balas-egaram, executive director of the MSF Access Campaign, in a press release. “The fact that the drug is active against drug-resistant forms of the disease makes it a potential game changer.”

The current treatment for multidrug-resis-tant TB (MDR-TB) is a 2-year course of up to 20 different pills per day and around 8 months of daily injections. [www.who.int/tb/chal-lenges/mdr/programmatic_guidelines_for_mdrtb/en/index.html Accessed on 14 January] Patients are subjected to excruciating side ef-fects, ranging from permanent deafness and persistent nausea to psychosis. Globally, only 48 percent of people who start treatment for drug resistant (DR)-TB are cured. In MSF pro-grams, the cure rate is slightly better – 53 per-cent – but still unacceptably low.

“Ministries of health and drug regulators need to work together to make sure people with MDR-TB benefit from this important medical advance as soon as possible. The onus is on all of us to use bedaquiline to devise new treatment regimens for drug-resistant TB that are shorter, more tolerable for patients, and are more effective,” said Balasegaram.

“With better treatment on the way, there should be all the more incentive to scale up our efforts to treat MDR-TB today.”

The scale of the DR-TB epidemic is huge, with 310,000 new cases notified in 2011. But globally, only 19 percent of people thought to be infected are receiving treatment.

“Scale-up of global DR-TB treatment has remained shockingly low, to a large degree because the current treatment regimen is so complex and costly for health programs and difficult to tolerate for patients,” said Dr. Francis Varaine, leader of MSF’s TB working group. “With simpler, shorter and more ef-fective treatment regimens, we will be able to scale-up treatment and cure more people with DR-TB.”

In addition to bedaquiline, developed by Janssen, a second new drug that is active against MDR-TB called delamanid, developed by Otsuka, is undergoing registration by the European Medicines Agency and is expected to be approved for use in 2013. Together, the two new drugs represent an unprecedented opportunity to improve treatment for MDR-TB, and it is extremely urgent to ensure the drugs are combined and introduced in the most effective manner.

But access to the new drugs will depend to a large degree on the manufacturers. MSF has called on manufacturers to make the drugs available for research in order to develop shorter, more effective regimens, to register them in high-burden countries as quickly as possible once they have been approved, and to ensure they are affordable in countries where they are needed most.

MSF treated 26,600 TB patients in 36 coun-tries in 2011 – 1,300 of whom had drug-resis-tant forms of the disease.

MDR-TB is defined as resistance to isoniazid and ri-fampicin, with or without resistance to other first-line drugs ie, ethambutol and pyrazinamide.

43 1-15 February 2013 Internat ional

Global study shows people living longerLeonard Yap

The first global study since 1990 on the burden of disease was released in mid-December 2012, detailing new es-

timates of life expectancy over the last 4 de-cades in 187 countries.

The Global Burden of Disease Study 2010 (GBD 2010) reported that life expectancy had increased continuously and substan-tially over the time period studied, but there remained a significant variation across age groups, among countries and over specific decades. Of the 187 countries studied, 179 reported increases in life expectancy. [Lancet 2012;380(9859):2095-128]

Headline findings• Great progress is being made in popula-

tion health, with life expectancies for men and women increasing. A greater propor-tion of deaths are taking place among people older than 70 years.

• A reduction of HIV and malaria burdens, but they remain a high priority.

• Fewer children younger than 5 years are dying.

• Infectious diseases are increasingly being controlled.

• In some parts of the world, there has been substantial progress in preventing premature deaths from heart disease and cancer.

The study reported a rising problem of noncommunicable diseases like cardiovas-cular disease and cancer. Cancer claimed the lives of 8 million people in 2010, more than a

30 percent increase from 20 years ago. Cardio-vascular disease, in particular heart disease and stroke, was responsible for one in four deaths across the populations studied.

According to study author Professor Ra-fael Lozano, of the Institute for Health Met-rics and Evaluation (IHME) at the University of Washington, Seattle, US, “Our analyses, for the first time, allow such comparative assessments and are important inputs into discussions about goals and targets for the post-Millennium Development Goal era. The rapid and global rise in premature death from leading noncommunicable diseases argues strongly for inclusion of these conditions, and their principal causes, in this agenda, particu-larly in view of their close relation to poverty reduction goals.”

GBD 2010 also highlighted the significance of disability from mental health disorders, substance use, musculoskeletal disease, dia-betes, chronic respiratory disease, anemia, and loss of vision and hearing. The study pro-jected that this type of disability will become increasingly important for all health systems. More people will be spending more years of their lives with more illnesses, and women will be particularly affected. Women aged 15 to 65 years are projected to lose more life in health to disability than men.

What is GBD 2010?GBD 2010 is a collaboration of 486 scien-

tists from 302 institutions in 50 countries. The study was launched in 2007 with a consor-tium of seven partners: Harvard University; the IHME at the University of Washington; Johns Hopkins University; the University of Queensland; Imperial College London; Uni-versity of Tokyo; and WHO.

44 1-15 February 2013 Internat ionalGBD 2010 was the first systematic and

comprehensive assessment of data on disease, injuries and risk since 1990. While the initial exercise was commissioned by the World Bank, GBD 2010 was supported by the Bill and Melinda Gates Foundation. The project had dramatically expanded in scope since its inception. In 1990, 107 diseases and injuries, together with 10 risk factors, were assessed. For 2010, 235 causes of death and 67 risk fac-tors are included.

In an accompanying commentary, Profes-sor Richard Horton, editor-in-chief of the Lancet and honorary professor at the London School of Hygiene and Tropical Medicine, said: “Publication of the GBD 2010 is a land-mark event for this journal and, we hope, for

health. The collaboration ... has produced an important contribution to our understand-ing of present and future health priorities for countries and the global community.” [Lancet 2012;380(9859):2053-4]

Horton suggested that GBD 2010 “should add energy and momentum to efforts to improve the measurement of health, es-pecially commitments to strengthen civil registration and vital statistics systems in countries. There is also every prospect that, instead of the GBD being a single event every few years, it will evolve into a continuous process of reviewing and up-dating data as new and more reliable in-formation, together with better methods, become available.”

MT IMPACT CCM PHarma Sobenz.pdf 1 12/20/12 9:59 AM

46 Calendar1-15 February 2013

ANNOUNCEMENT

London College of Clinical Hypnosis and Academy of Family Physicians of Malaysia Certificate in Clinical Hypnosis16/3; Kuala LumpurInfo : LCCH SecretariatTel : (03) 7960 6439Fax : (03) 7960 6449Email : [email protected]

MALAYSIA EVENTS

February

Malaysian Society of Hypertension 10th Annual Scientific Meeting1/2 to 3/2; Kuala LumpurInfo : SecretariatTel : (03) 7948 1888Fax : (03) 7948 1818Email : [email protected] [email protected]

March

Sleep 201313/3 to 16/3; SelangorInfo : Secretariat Tel : (03) 6126 4837Fax : (03) 6120 3423http://sleepsocietymalaysia.org/

Coloproctology14/3 to 16/3; Kuala LumpurInfo : SecretariatTel : (03) 4023 4700 Fax : (03) 4023 8100Email : [email protected]/Coloproctology2013

International Society for Pediatric Neurosurgery (ISPN) Course 201316/3 to 18/3; Kuala LumpurInfo : SecretariatTel : (03)4023 4700 /4025 3700Fax : (03) 4023 8100Email : [email protected]://www.acadmed.org.my/eventsmaster.cfm?&menuid=33&action=viewevent&retrieveid=255

Paediatric Anaesthesia Meeting PAM 201322/3 to 23/3; Kuala LumpurInfo : SecretariatTel : (03)4023 4700 /4025 4700Fax : (03) 4023 8100Email : [email protected]

April

9th Asian Society for Paediatric Research18/4 to 21/4; KuchingInfo : Ms. YM KongTel : (03) 4023 4700 (03) 4023 5700Fax : (03) 4023 8100Email : [email protected]

WOOMB International Conference 26/4 to 28/4; KuchingInfo : Dr. Chan Lek-Lim Tel : (013) 810 7004 (082) 423 226Fax : (082) 578 682Email : [email protected] [email protected] [email protected]

Medical Disability Seminar – Approach to Medical Disabilities and Medico-legal issues in Malaysia27/4 to 28/4; Kuala LumpurInfo : Ms. Ranuga Devy Tel : (03) 2070 5660Fax : (03) 2072 5660Emai : [email protected]


May

Diabetes & Complications Symposiums / Grand Rounds17/5 to 19/5; Kuala LumpurInfo : NADITel : (03) 7876 1676 / 7876 1677Fax : (03) 7876 1679Email : [email protected]

June

8th Asean Conference On Primary Health Care7/6 to 9/6; IpohInfo : SecretariatTel : (05) 242 6549Email : [email protected]

4th National Diabetes Conference14/6 to 15/6; Kuala LumpurInfo : Ms. ParameasTel : (03) 7957 4062 /4063 Fax : (03) 7960 4514Email : [email protected]

MALAYSIA EVENTS

6th National Conference for Clinical Research 18/6 to 23/6; KuchingInfo : Amy Yu Bee LingTel : (03) 4043 3809 / : (016) 263 2818Fax : (03) 4043 3808Email : [email protected]

12th Asean and Oceanic Society of Regional Anaesthesia & Pain Medicine Congress19/6 to 22/6; KuchingInfo : SecretariatTel : (03) 4023 4700 (03) 4025 4700 (03) 4025 3700Fax : (03) 4023 8100Email : [email protected]

10th Liver Update20/6 to 23/6, Kuala LumpurInfo : SecretariatTel : (03) 7842 6101Fax : (03) 7842 6107www.liver.org.my


INTERNATIONAL EVENTS

February

Asia Pacific Society of Cardiology (APSC 2013) Congress21/2 to 24/2; Pattaya, ThailandInfo : SecretariatEmail : [email protected]/apsc2013/Pages/Home.aspx

March

62nd American College of Cardiology (ACC) Annual Scientific Session9/3 to 11/3; San Francisco, USInfo : SecretariatEmail : [email protected]://accscientificsession.cardiosource.org/ACC.aspx

April

European Congress on Osteoporosis and Osteoarthritis (ECCE013-IOF)17/4 to 20/4; Rome, ItalyInfo : SecretariatEmail : [email protected]://www.ecceo13-iof.org/

June

World Congress of Nephrology 201331/5 to 4/6; Hong KongInfo : SecretariatEmail : [email protected]://www.wcn2013.org/

23rd Conference of the Asian Pacific Association for the Study of the Liver6/6 to 9/6; SingaporeInfo : SecretariatEmail : [email protected]

2013 Annual Meeting of American Society of Clinical Oncology (ASCO)31/5 to 4/6; Chicago, USInfo : Secretariathttp://chicago2013.asco.org/

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