PHILIPPINES MARCH 2015

New dengue vaccine deemed effective and safe

FEATURELudan’s method and Dr Ludan’s other legacies to pediatrics

FORUMIncineration: Impact on health and climate

MARKET WATCHThe Medical City offers transradial catheterization

NEWSTraining course effective in preparing to respond to Ebola

20-22 August 2015 • Singapore • Raffles City Convention Centre

The Synthesis of Evidence, Experience, and Choice in Women’s Health Call for Abstracts, Registration,and Programme atwww.sicog2015.com

DR CAROL TAN

A novel vaccine against dengue has been

found to be effective and safe, based on

a randomized controlled trial conducted by Dr

Maria Rosario Capedeng, et al.

The study was a phase three multi-centered

trial held in five Asia-Pacific countries. Healthy

children aged two to fourteen years were ran-

domly assigned to receive three injections of

either recombinant live attenuated, tetravalent

dengue vaccine (CYD-TDV) or placebo, given

six months apart (months 0, 6, and 12) at three

centers in Indonesia, two centers in Malaysia,

two centers in the Philippines, three centers in

Thailand, and two centers in Vietnam. A total of

10,275 children were included in the study, with

6,851 children receiving the dengue vaccine

and 3,424 children receiving placebo. The par-

ticipants were then followed up for 25 months

to determine whether they developed dengue

infection or any serious adverse events. The

primary endpoint of the study was for the lower

bound of the 95 percent confidence interval of

vaccine efficacy to be greater than 25 percent.

[Lancet 2014;384;9951:1358-65.]

Outstanding resultsResults of the study showed that a total of

250 cases of virologically confirmed dengue

were recorded more than 28 days after the third

injection. Out of the 250 cases, 47 percent or

117 cases occurred in the vaccine group, while

53 percent or 133 cases occurred in the control

group. The vaccine efficacy was computed at

56.5 percent with a 95 percent confidence in-

terval of 43.8 to 66.4 percent; thus, the study’s

primary endpoint was met.

Furthermore, the authors reported that the

dengue infections were found to be milder in the

vaccine group than in the control group. Only

40 participants (less than 1 percent) from the

vaccine group necessitated hospital admission

due to virologically confirmed dengue infection,

compared to 61 participants (two percent) from

the control group. The vaccine efficacy against

hospitalized dengue was computed at 67.2 per-

cent, with a 95 percent confidence interval of

50.3 to 78.6 percent.

There were a total of 647 serious adverse

events recorded in the study, of which 402

events occurred in the vaccine group and 245

events occurred in the control group. Only 54

participants (one percent) in the vaccine group

and 33 participants (one percent) in the control

group had serious adverse events occurring

MARCH 2015 3

New dengue vaccine deemed effective and safe

within 28 days of the vaccination. These adverse

events were mainly infections and injuries that

were consistent with common medical disorders

observed in the age group of the participants.

The authors concluded the dengue vaccine

is effective when given as a three-dose series to

children living in endemic areas, and has a good

safety profile. Although the vaccine only has a

moderate over-all efficacy, it can still have a sub-

stantial public health benefit especially consid-

ering the high disease burden of dengue in Asia.

Award-winning publicationThis publication was awarded Paper of the

Year 2014 by the International Society of Vac-

cines. The principal investigator of the study

is Dr. Capedeng, who is head of the Research

Institute of Tropical Medicine of the Philippine’s

Department of Health. She was also included in

the 2014’s list of Top Women in Biotech Industry.

Controversies on ‘breakthrough’ dengue drug

Meanwhile, another experimental approach

to dengue was axed. The Department of Health

(DOH), led by acting health secretary Janette

Garin has suspended a local clinical trial of the

controversial ActRx TriAct. The ActRx TriAct is

a combination of the compounds artemether,

artesunate, and an herbal compound called ber-

berine. This drug was said to be a breakthrough

drug for dengue, and was approved to be dis-

tributed to six government hospitals as part of a

clinical trial.

Garin stated that this drug cannot be used

in clinical trials since it has not yet been reg-

istered with the Food and Drug Administra-

tion (FDA Philippines). According to DOH,

the trial did not comply with the International

Conference on Harmonization Guidelines for

Good Clinical Practice. This finding was sup-

ported by the Philippine Council for Health

Research and Development, which stated that

the study lacks scientific justification for the

use of artemether and artesunate for dengue

treatment.

According to DOH, the researchers behind

this clinical trial must be held accountable.

Aside from endangering the lives of the partici-

pants included in the study, the ActRx TriAct also

has a potentially disastrous public health effect.

Artemether and artesunate are both made from

artemesin, which is a drug used for malaria. To

prevent drug resistance, artemesin is adminis-

tered with other drugs such as lumifrantrine and

primaquine in the treatment regimen for malaria.

In the ActRx TriAct, artemether and artesunate

are used as monotherapy, which may increase

the development of resistance to this important

anti-malarial drug.

Dr. Francisco Tranquilino, regent of the Phil-

ippine College of Physicians Board, agreed

that the clinical trial is technically and ethically

flawed, and should not have been initiated at

all. Dr. Maria Minerva Calimag, president of the

Philippine Medical Association, shares the same

sentiment. She explained that a drug that is ef-

fective for malaria cannot be presumed to be ef-

fective for dengue, since malaria is caused by

a protozoa while dengue is caused by a virus.

The WHO representative to the Philippines, Dr.

Julie Hall, emphasized that artemisin is a pre-

MARCH 2015 4

cious public health drug and should be used ju-

diciously to prevent drug resistance.

Other updates in dengue managementDue to the changes in the epidemiology of

dengue over the past years, a new classification

was created by the World Health Organization

(WHO) last 2012. Patients are now classified as

having dengue without warning signs, dengue

with warning signs, or severe dengue.

Patients are labeled as dengue without warn-

ing signs if they live in or travel to dengue-en-

demic areas, and experience fever with any two

of the following symptoms—headache, body

malaise, myalgia, arthralgia, retro-orbital pain,

anorexia, nausea, vomiting, diarrhea, flushed

skin, and rash. These patients must also have

leucopenia with or without thrombocytopenia

on complete blood count, or a positive dengue

NS1 antigen or IgM antibody test.

The criteria for dengue with warning signs

consist of patients who live in or travel to den-

gue-endemic areas, with fever lasting for two to

seven days. They must also exhibit at least one

of the warning signs, such as abdominal pain or

tenderness, persistent vomiting, clinical signs of

fluid accumulation, mucosal bleeding, lethargy,

restlessness, liver enlargement, an increasing

hematocrit, or a decreasing platelet count.

Patients are classified as severe dengue

when they fulfill the criteria for dengue with or

without warning signs, plus any one of the follow-

ing—severe plasma leakage leading to shock or

fluid accumulation causing respiratory distress,

severe bleeding, or severe organ impairment.

Specifically, the WHO quantified organ impair-

ment as an AST or ALT level of at least 1000 for

the liver, the presence of seizures or impaired

consciousness for the brain, myocarditis for the

heart, and renal failure for the kidneys.

Aside from the proper classification and

management of dengue, the WHO continues

to emphasize that environmental manage-

ment is an important tool to control the burden

of disease. Several environmental strategies

are espoused by the WHO to minimize vec-

tor propagation. The supply of water and wa-

ter storage systems must be improved so that

water-storage containers that serve as larval

habitats are no longer necessary. Water-storage

containers must also be fitted with tight lids to

keep the mosquitoes out. Proper solid waste

management must also be practiced to reduce

larval habitats. Guidelines for the safe use of

insecticides are also enumerated in the WHO

dengue guidelines.

MARCH 2015 5

MARCH 2015 6

DR MEL M BELUAN

T he Department of Health (DOH) has report-

ed last March 11 at least one person in the

country tested positive for the Middle East Re-

spiratory Syndrome-Coronavirus (MERS-CoV).

The patient is a 32-year-old female nurse who

underwent testing when she exhibited flu-like

symptoms upon arrival in Manila from Saudi

Arabia last March 1, 2015.

DOH secretary Dr Janette Garin confirmed on

March 12 that the patient is 4 to 5 weeks pregnant,

making her situation precarious as pregnancy ren-

ders the immune system weaker. She stressed that

while her baby would likely not get infected, the

baby’s health depends on her condition.

As of March 12, the patient no longer had

fever and was in stable condition while being

observed in a negative-pressure room at the De-

partment of Health’s Research Institute for Tropi-

cal Medicine (RITM) in Muntinlupa City. Her hus-

band who arrived with her from the same flight is

also being monitored for symptoms in the same

room. It has to be recalled that a Filipino nurse,

who was tested in Saudi Arabia, entered the

country in September of last year. The nurse’s

test later came out positive.

The DOH has already traced 92 of the 225

other Saudi Airline flight 860 passengers, who

agreed to be tested. It is also observing other 56

individuals whom the nurse had close contact

with. Ten of them had contact with her when she

was admitted earlier in a hospital. The nose and

throat swab samples of the 56 contacts were

negative for the virus in the first round of tests.

However, 11 symptomatic contacts were admit-

ted at the RITM and would have another round

of tests using sputum and rectal swab samples.

Experts said that the risk of infecting other

passengers is low as the patient did not show

any symptoms while aboard the flight. MERS-

CoV has a mortality of 30 percent but human-

to-human transmission is difficult. As DOH de-

clared preparedness to handle the disease, it

also advised the public to be aware of its flu-like

symptoms such as fever, body pain and difficul-

ty of breathing. The agency asked uncontacted

passengers to communicate with them through

the numbers (02) 711-1001 or (02) 711-1002 if

they are having flu-like symptoms.

The emergency committee (EC) of the WHO

no longer considers MERS-CoV a Public Health

Emergency of International Concern (PHEIC). As

of MARCH 5, it noted 971 laboratory-confirmed

cases , including at least 356 deaths. MERS-CoV

was first reported in Saudi Arabia in 2012.

DOH confirms MERS-CoV case in the country

MARCH 2015 FORUM 7

Incineration: Public health impact, climate change implications and the Ebola epidemicDR MARY LAUREN EUROPA

Last January 28, the non-governmental or-

ganization Health Care Without Harm held

the forum “Incineration: Public Health Impact,

Climate Change Implications, and the Ebola Cri-

sis“ in Quezon City. The main speaker was Dr

Jorge Emmanuel, a renowned environmental-

ist and chief technical adviser on Health Care

Waste for the United Nations.

Emmanuel began by defining the precaution-

ary principle to unite the topics on incineration,

public health, climate change and the Ebola

crisis. This principle is the responsibility of ev-

ery decision-maker regarding evidence about

harmful effects of certain on human health and

the environment “[This] principle requires that

one should make a decision on the side of pre-

caution, and on the side protecting public health

and the environment,” he says.

Medical waste incineration (MWI) and dioxins

The main public health and environmental

implication of medical waste incineration is the

production of carcinogens called dioxins. In Eu-

rope, 62 percent of dioxin emissions are due to

technological processes, including MWI. In the

US, non-incineration methods resulted in a drop

of dioxin emissions from MWI, from 2470 g TEQ

(toxic equivalents) per year in 1987, to only 477

g TEQ/yr in 1995; despite that, MWI is still the

third largest source of dioxins. Moreover, “[i]

ncineration also releases other toxic pollutants,

like lead, cadmium, and mercury, acid gases,

carbon monoxide, particulate matter, incinerator

ash, and other organic compounds ,” adds Em-

manuel.

Dioxins and health effects“Dioxins” are a family of polychlorinated

dibenzo-p-dioxins and dibenzofurans, which are

extremely toxic . “Their effects are appreciated

at doses of parts per billion, or trillion,” says Em-

manuel, “like a drop of water in a medium sized-

lake.” Based on animal studies, the US Environ-

mental Protection Agency developed a cancer

potency factor in 2002, which pegged dioxin

at 0.000000000001 g TEQ/kg/day. In humans,

dioxins have been noted to produce develop-

mental malformations and birth defects, cogni-

tive retardation, and changes in sex ratio (fewer

male births). Dioxins also suppress the immune

system, decrease fertility and increase cases of

endometriosis in females, and decrease testos-

terone levels, sperm count, and penis and tes-

ticular size in males.

Dioxins are extremely persistent, with an

environmental half-life ranging from 9 to more

than 1000 years. Emmanuel stressed that this

makes the precautionary principle relevant,

because releasing dioxins today will affect not

only our lives, but the lives of future genera-

tions.

MARCH 2015 FORUM 8

Studies on the health effects of incinerationMany studies have been done on residents

living within a radius of about 10 km or less to

incinerators, and on the industrial workers at

these sites. These studies linked incineration

to cancers of the larynx, stomach, lung, colon,

rectum, and liver, and lung, with closer proxim-

ity to incinerators; high serum levels of lead,

cadmium and toluene, and urinary levels of tet-

rachlorophenols and arsenic; deaths from isch-

emic heart disease and lung cancer; and lethal

congenital anomalies and stillbirths near incin-

erators.(1-7)

Best available techniques The results of the studies led to the develop-

ment of regulations on dioxins. Emmanuel is a

member of the expert panel group that devel-

oped the guidelines for Best Available Tech-

niques (BAT) and Best Environmental Practices

under the Stockholm Convention, which seeks

to limit dioxin production and environmental

release. The limits may be achieved through

a suitable combination of primary and second-

ary measures, says Emmanuel. Primary mea-

sures would ensure the introduction of waste at

850°C or higher, as most dioxins are produced

during the transit periods of incinerators, when

the waste materials are introduced, and the tem-

peratures slightly dip down below 850°C.

Secondary measures are important, as it will

be unlikely to reduce dioxin production to ac-

ceptable levels with primary measures alone.

This would necessitate the use of technologies

that meet international standards, and would

include dedusting, with the fabric and ceramic

filters operating at optimum temperatures; the

use of cyclones for pre-cleaning; electrostatic

precipitators around 450°C; and the inclusion

of high performance adsorption units with acti-

vated carbon.

Non-incineration alternativesAn alternative to incineration is steam or auto-

clave-based systems. Autoclaves are markedly

cheaper to produce and maintain. According to

Emmanuel, due to political and business con-

siderations, more incinerators than autoclaves

are still being used, as they yield bigger profits.

There are advantages, however, in shifting to a

steam-based or autoclaving technology. This

would entail a shift from a “waste management”

to a “resource management” framework. Many

of the health care waste materials can now be

reusable and recycled after treatment.

An ideal medical waste management sys-

tem, however, is not dependent on technology,

but on a system that integrates waste classifica-

tion, segregation, minimization, systematic con-

tainerization, color coding, labeling, signage,

handling, transport, storage, treatment and final

disposal, and wastewater treatment and contin-

gency plans.

Successful health care waste management (HCWM) projects

An example of a successful HCWM project

spearheaded by Emmanuel was the India Proj-

ect (2010 – 2012) at the King George Medical

University Hospital. The hospital previously had

no proper HCWM, exemplified by poorly han-

dled infectious waste deposited at uncontrolled

dumpsites or burned in a makeshift incinerator.

Emmanuel’s team instituted storage and treat-

ment facilities with autoclaves and shredders,

color-coded segregation bins, informational

MARCH 2015 FORUM 9

posters and training, improved internal trans-

port system, waste tracking and CCTV systems.

These improvements led to the development

of an HCWM committee, a committed hospital

leadership and an infection control program.

Furthermore, recovery of recyclables provided

revenues which helped maintain the HCWM

system.

Emmanuel also participated in the Kyrgystan

Project (2005-2013). Kyrgystan, one of the poor-

est countries of the former Soviet Union, had

no national regulation on medical waste, and

little or no segregation of waste. After a national

assessment, Emmanuel’s team developed a

HCWM model which made use of reusable con-

tainers, waste minimization and recycling. By

the end of the program, all hospitals, primary

health centers and private clinics started to use

the model. Hospitals even reported a 33 percent

savings, and generated revenue from recycling.

Ebola crisisEmmanuel was also involved in the Ebola

Waste Project (2014). Incineration, which was

already problematic, was in place. In addition,

says Emmanuel, it poses hazards to workers, as

their personal protective equipment (PPE) have

combustible properties. This was addressed by

Emmanuel’s team via the establishment of au-

toclaves and HCWM guidelines. The autoclaves

were started to be built in Africa, instead of be-

ing imported, thereby reducing the overhead

costs. These systems made use of steam ejec-

tors instead of vacuum pumps, and mechanical

controls instead of computer controls, resulting

in fewer maintenance issues, and greater waste

volume reduction. These autoclaves could also

ride through power outages. According to Em-

manuel, these autoclaves exceeded interna-

tional standards, and are an excellent solution

to this Ebola crisis, for the following reasons: the

Ebola virus is destroyed by autoclaving within

seconds to minutes; the process does not re-

lease smoke, dioxins, hydrochloric acid, or other

toxic air pollutants; it is safe for workers wearing

PPE; special barrel trolleys protect workers from

Ebola exposure, and these are cheaper than in-

cinerators.

Climate change impact Emmanuel also talked about climate change

and global warming, to which emissions of in-

cinerators are contributory. “[There have been

marked increases in global carbon dioxide

(CO2) levels], with levels reaching 400 ppm for

the first time in human history in 2013,” he says.

Global climate change would impact heavily on

Southeast Asian countries like the Philippines.

Emmanuel states that Intergovernmental Panel

on Climate Change 4th Assessment and ADB

Reports mentioned potentially pervasive envi-

ronmental, health and socioeconomic effects.

Emmanuel ended his talk with a vision of an

alternative path in waste management: a para-

digm shift to recycling, conservation of earth’s

resources, and aiming for zero-waste and re-

newable clean energy.

References: 1. Occup Environ Med 1998;55:611-15. 2. Am J Ind Medi-cine 1997;31:659-61. 3. Environ Health Perspect 1996;104:750-54. 4. Br J Cancer 1996;73:702-10. 5. Int Arch Occup Environ Health 1995;68:13-21. 6. Am J Ind Medicine 1989;15:129-37. 7. J Epidemiol Commun H 2003;57:456-61.

MARCH 2015 NEWS 10

Training course effective in preparing Philippine hospitals to respond to Ebola virus diseaseDR JAMES SALISI

A three-day training course to prepare hospi-

tal staff for Ebola virus disease (EVD) was

“effective at increasing the level of knowledge

about EVD and the level of confidence in man-

aging EVD safely,” according to an article pub-

lished on the Western Pacific Surveillance and Response Journal. A total of 364 doctors, nurs-

es and medical technologists from 78 hospitals

across the Philippines were trained. Evaluation

of the workshop found significant increases in

knowledge about EVD (P<0.009) and confi-

dence in managing EVD (P = 0.018). [WPSAR 2015;6(1). doi:10.5365/wpsar.2014.5.4.008]

This comes as positive news in the midst of

heightened awareness and anxiety over the on-

going spread of EVD in Liberia and Sierra Leone

in Africa. Fear of this condition is borne out of

the high case fatality rates that could go up to 70

percent. The case fatality rates are 55 percent

for healthcare workers and 58 to 60 percent for

hospitalized patients according to the WHO.

Although the Western African EVD has not

reached the Philippines, the training was orga-

nized to increase the capacity to detect, isolate

and safely care for EVD cases in the country

should this come to pass. The WHO declared

on August 8, 2014 the West African EVD out-

break as a public health emergency of inter-

national concern (PHEIC). Under International

Health Regulations (2005), signatory govern-

ments like the Philippines are obliged to “de-

velop, strengthen and maintain public health

capacities for surveillance and response to be

able to detect, assess, notify and report events

and respond to a PHEIC.”

While the Philippines’ Department of Health

(DOH) has a robust surveillance system and

has experience in managing emerging and re-

emerging infectious diseases, the training was

in preparation for the possibility of introduction

of cases through travellers from affected coun-

tries and returning overseas Filipino workers.

The Research Institute for Tropical Medicine

(RITM), which is the DOH’s research institute

for infectious diseases, the WHO country of-

fice, and consultants employed by WHO as pri-

vate individuals or from Johns Hopkins Hospi-

MARCH 2015 NEWS 11

CONTINUED TO NEXT PAGE

tal and Tropical Health Solutions collaborated

to develop the curriculum and content of the

training.

The training was spread over three days of

workshops that consisted of 18 lectures and

10 practical or small group sessions, includ-

ing three practical sessions to put on and put

off personal protective equipment (PPE). Each

participant was given his own set of PPE ex-

cluding rubber boots to use during the work-

shop. PPEs are an essential part of controlling

the spread of EVD and protecting the health-

care workers involved in the care from falling

ill from EVD themselves. The lectures provided

participants with the knowledge base on Ebo-

la, detection and management, ethical issues

concerning clinical activities in EVD patients,

prevention and control, hospital waste man-

agement in relation to EVD, epidemic manage-

ment, laboratory procedures, biosafety and re-

ferral system.

Evaluation tools used in the training were

developed by WHO consultants and piloted on

RITM medical and nursing staff, and included

a pre- and post-workshop test, two evalua-

tion forms post-workshop and One Minute Re-

flections (OMR). The results of the evaluation

showed marked improvement in knowledge.

The participants’ median scores rose from sev-

en (7 correct answers out of 10 in the pre-test)

before the workshop to nine (9/10).

Similarly, confidence in safely caring for an

EVD patient rose markedly by the end of the

workshop. The percentage of participants who

disagreed or strongly disagreed with the state-

ment: “I am confident that I can be safe when

caring for a patient with Ebola virus disease,” fell

from 27.3 to 2.6 percent. Following the trend, the

percentage of participant who agreed or strongly

agreed with the statement rose from 32.5 to 87.2

percent.

The Department for International Develop-

ment UK funded the development an evaluation

of the training and employment of WHO consul-

tants; the DOH financed the conduction of the

training. The staff of RITM, DOH and WHO were

supported by their respective employers under

routine funding.

MARCH 2015 NEWS 12

Researchers to locally develop 3D-printed human organsDR MEL M BELUAN

T he Lung Center of the Philippines (LCP) in

collaboration with the Technological Insti-

tute of the Philippines (TIP) will be doing a study

on using genomics and three-dimensional print-

ing to create an artificial trachea for transplanta-

tion.

Signing a memorandum of agreement last

MARCH 18, researchers from LCP and TIP

would develop an interdisciplinary platform to

enable doctors to create a simple trachea, and

eventually more complex organs such as the

lungs, kidney and heart.

In a statement, LCP executive director Dr

Jose Luis J Danguilan said, “If we are success-

ful in its clinical applications, we may be at par

with the advanced nations in this new field ... an

artificial trachea could be made available in the

country in the next 3 to 4 years.”

The research, the country’s first, will come up

with 3D-printable biocompatible materials with

the help of TIP’s engineers. The technology

involves “weaving a bio-ink” using the nano-

technological concept of electrospinning which

mimics the web-spinning of spiders. After an or-

gan scaffold is built, it will be impregnated with

stem cells derived from the patient’s fat tissue or

bone marrow. The nascent “organ” will then be

allowed to incubate in a bioreactor. Prototypes

of the bioreactor and electrospinning device

were already developed by TIP researchers.

The technology’s biggest potential impact

would be helping to address the long lines of

would-be organ recipients looking for compat-

ible donors. Since this technology uses tissue

from autologous sources (ie, the patient’s own

stem cells), transplantation can occur without

donor-matching, organ shortage and immuno-

suppressive medication.

In a press release, TIP’s Dr Custer Deocaris,

a DOST Balik Scientist, described the scenario:

“In the near future, here in our own country, you

will visit the hospital and request your attend-

ing physician for the procedure. A complete

organ that looks like jell-o will be bio-printed by

a technician with a mere press of the ‘print’ but-

ton on a computer hooked-up to a 3D printer.

After you have provided stem cells, with either

a liposuction or a bone marrow extraction pro-

cedure, in just one week, your new organ is

ready for use.”

For years, researchers have been able to

3D-bioprint simple tissues such as tissues of

the skin, heart and blood vessels. In 2008, the

world’s first ever transplant of a more complex

structure, a bioengineered autologous trachea,

was performed by Dr Paolo Macchiarini in Swe-

den. Scientists in Australia and the US are now

trying to bioprint other organs.

MARCH 2015 FEATURE 14

Occupational medicine more relevant in today’s growing industries DR LOUELL L SALA

A s the country grapples with health and

safety issues associated with increasing

industrialization, occupational medicine (OM) is

becoming more important. In the recently con-

cluded second batch of the diplomate course

of the Philippine College of Occupational Medi-

cine (PCOM) held last MARCH 1, 2015 at the

Occupational Health and Safety Center (OSHC)

in Quezon City, 43 physicians from all over the

Philippines underwent training on regulations,

legislations, emerging Issues and common

practices in OM.

Overseen by the chair of the residency train-

ing program Dr Marilou D. Renales, the PCOM

diplomate course is conducted for doctors and

PCOM members who have completed the Basic

Course in Occupational Medicine (BCOM) and

with at least 2 years of active practice in OM.

Occupational medicine at a glanceIn an age when the worker’s health and safety

only becomes an issue after an incident, the oc-

cupational medicine specialty answered the call

of preventing work-related accidents and dis-

eases. Started in 1700 by an Italian physician,

Dr. Bernardino Ramazzini, who recognized the

relationship between lead and antimony and the

symptoms of poisoning in painters and other ar-

tisans,(1) OM has gone a long way in creating

a venue for management, the worker, and the

regulatory bodies of the government to meet.

In an effort to recognize that employment and

working conditions have powerful effects on

health equity,(2) the WHO urges member states

to connect health and labor, with emphasis

on primary prevention. And with this goal, the

Philippine College of Occupational Medicine

(PCOM) works hand in hand with the WHO and

other partners in the delivery of health services

for the workers.(3)

OM in the PhilippinesPCOM is the Institution accredited by the

Department of Labor and Employment (DOLE)

to conduct the Basic Occupational Safety and

Health (BOSH) and the diplomate course of OM.

Established in 1966,(3) it is a prime mover in the

preservation, promotion, protection, enhance-

ment of health, wellness, and safety of workers

in all occupations. It has been an active special-

ty accredited by the Philippine Medical Associa-

tion PMA and the Philippine Health Insurance

MARCH 2015 FEATURE 15

Corporation (PhilHealth).

Headed by national president Dr Oscar San-

tiano and vice-president Dr Gilbert Gille, PCOM

has 2500 members all over the country and is

growing. Presently, there are 23 chapters and

these are all organized to address the emerging

challenges in the practice of occupational medi-

cine in their respective areas.(3)

OM specialists are adept at creating policies

with regards to sickness absence, work-related

stress and work-related accidents. In the coun-

try where there are growing numbers of the

business process outsourcing (BPO) industries

employing young workers, all of which are ex-

posed to various health and safety hazards, the

function of the OM physician is crucial in ad-

dressing these issues. More than identifying the

different hazards in the workplace, OM special-

ists are also proficient at implementing Occupa-

tional Safety and Health (OSH) programs which

enhance productivity and contribute greatly to

national economic development efforts.

Important issuances on occupational safety and health

Rule 1960 of DOLE’s Standards of Occu-

pational Safety and Health requires every em-

ployer to provide in his workplace medical and

dental services, emergency medicines and den-

tal facilities. Hazardous workplaces with 100 to

199 employees only need to be serviced by a

part-time OM physician. Workplaces with 601 or

more employees require the full-time service of

an OM physician.(4)

Another group of very important issuances

which requires the specialization of OM physi-

cians deals with assisting the companies imple-

ment guidelines from DOLE. These guidelines,

which include drug-free workplace,(5) tubercu-

losis,(6) HIV/AIDS(5) and hepatitis,(5) have to be

translated into the policies of the company.

Bound by a common principle of ensuring

worker’s health, the protection and promotion

of health at work, the diplomate course of oc-

cupational medicine ensures that the physician

has the necessary competence in understand-

ing the complicated paradigm of worker, man-

agement, and the regulatory bodies of the gov-

ernment.

References 1. Mednet resources page. Medicine Network web-site. Available at http://www.medicinenet.com/script/main/art.asp?articlekey=18430. Accessed 15 March 2015. 2. WHO resources page. World Health Organization website. Available at http://www.who.int/occupational_health/publications/global_plan/en. Accessed 15 March 2015. 3. PCOM resources page. Philippine College of Oc-cupational Medicine website. Available at http://www.pcom.ph/about-us. Accessed. 15 March 2015. 4. OSHC resources page. Occupa-tional S afety and Health Center website. Available at http://www.oshc.dole.gov.ph/UserFiles/oshc2010/file/OSH_Standards_Amend-ed_1989_Latest.pdf. Accessed 15 March 2015. 5. OSHC resources page Occupational Safety and Health Center website. Available at http://www.oshc.dole.gov.ph. Accessed 15 March 2015. 6. OSHC re-sources page. Occupational Safety and Health Center website. Avail-able at http://cloud.eacomm.com/oshc2010/UserFiles/oshc2010/file/DO-73-05-Guidelines-for-Implementation-of-TB-Prevention-in-the-Workplace.pdf. Accessed 15 March 2015.

MARCH 2015 FEATURE 16

The depressed employee and the workplaceDR PAOLO L MENDOZA

“ Whatever happens today, it is because of

my girlfriend“

A call center agent posted the above and

jumped off the rooftop of the i2 Building, IT Park

Lahug, Cebu City last August 16, 2014. The

man committed suicide after his girlfriend had

broken up with him. As posted on his Facebook

account, he couldn’t accept the fact that she left

him “for no reason and that hurts me the most,

especially seeing her with other guys dancing,

laughing and having fun.”

Industrial and socioeconomic growth in the

Philippines means more and more workers are

subject to mental stress associated with work

and non-work activities. According to the Cen-

ters for Disease Control and Prevention, the

mental health of workers is an increasing con-

cern. Depression is estimated to cause 200 mil-

lion lost workdays each year at a cost to em-

ployers of USD17 to 44 billion.(1)

Studies have identified depression as a ma-

jor cause of disability, absenteeism, presentee-

ism and loss of productivity.(2-4) Despite the evi-

dence linking job stress and depression, there

is still predilection to allocate resources to gen-

eral medical care. This is further complicated

by the poor financial capacity of the employer.

There is limited data regarding evidence of ef-

fective intervention to prevent depression at

work.(5)

Workplace as hostile environmentDepression can affect anyone.(6) It is multi-

faceted in the workplace setting, primarily influ-

enced by factors such as neurotransmitters, ge-

netic predisposition, development of personality

traits and temperament, and gender.(7)

The US National Survey on Drug Use and

Health (2007) showed that rates of depression

vary by occupation and industry. Major depres-

sive episode was found in the personal care

and service occupations (10.8 percent) and the

food preparation and serving occupations (10.3

percent).(6) Common job stressors include high

job demands, low job control and lack of so-

cial support.(5) Work- and non-work-related risk

factors play a role in causing more job stress

which may contribute to depression.(6)

In the Gallup-Healthways Well-Being Index,

77 percent of workers across 14 major occupa-

tions have been identified of having a chronic

health condition (asthma, cancer, depression,

diabetes, heart attack, high blood pressure, high

cholesterol or obesity). The total annual costs

related to lost productivity totaled USD84 billion.

Burden to employersPatients with depression miss 4.8 workdays

and suffer 11.5 days of reduced productivity

within a 3-month period.(2) About 80 percent of

depressed persons reported functional impair-

ment, and 27 percent reported serious difficulties

in work and home life. Only 29 percent reported

MARCH 2015 FEATURE 17

contacting a mental health professional.(4)

Absenteeism is difficult to monitor, control

and reduce, as it is simultaneously a legitimate

and poor excuse for missing work. The occupa-

tional medicine physician should examine and

update existing organizational practices and

redefine aspects of job design to reduce stress

and decrease the risk of poor mental health.

In addition to direct costs, depression also

increases indirect costs by contributing to oth-

er costly conditions. According to Finch et al

(2005), an individual’s risk of depression is near-

ly doubled in the presence of type 2 diabetes

mellitus.(9) However, Campbell et al suggests

that 80 percent of patients with depression will

improve with treatment.(10)

Challenges to the behavioral healthcare system

Though employers recognize that behavior-

al health benefits are essential components of

health care, it is not customary to integrate it to

the health benefit plan for employees.(9)

Several issues complicate the behavioral

health care. In the Philippines, many health

maintenance organizations are limited in pro-

viding employees with the services of psychia-

trists and neurologists. As of late, consumerist

healthcare will continue to affect the delivery of

behavioral health care.(9)

Among the strategies that employers can

pursue include depression screenings; confi-

dential self-rating sheets; awareness programs;

depression recognition training; and access to

psychiatric services.(10) The Employer’s Guide

to Behavioral Health Services by Finch and

Philips provides information for the physician

and the employer in managing the employee’s

health status, productivity, and disability and

healthcare costs.(9)

References 1.. JAMA 2003 Jun 18;289:3135-3144. 2. Ann Intern Med 2001; 134: 345-360. 3. Geriatrics and mental health—the facts. Avail-able at: http://www.aagponline.org/prof/facts_mh.aspicon_out [ac-cessed Feb 17, 2015]. 4. NCHS Data Brief No. 7; 2008. Available at: http://www.cdc.gov/nchs/data/databriefs/db07.htm#ref08. [Ac-cessed Feb 17 2015]. 5. Preventing occupational disease and injury. 2nd ed. (2005). 6. Depression in the Working Population: Position Statement (2009). Available at: http://www.acoem.org/guidelines.aspx?id=5613 [Accessed Feb 17, 2015] 7. The NSDUH Report (2007). Available at:http://www.oas.samhsa.gov/2k7/depression/occupation.htmicon_out.[Accessed Feb 17, 2015]. 8. The causes and costs of absenteeism in the workplace. Available at: http://www.forbes.com/sites/investopedia/2013/07/10/the-causes-and-costs-of-absenteeism-in-the-workplace/. [Accessed Feb 17, 2015]. 9. An Employer’s Guide to Behavioral Health Services: A Road map and Recommendations for Evaluating, Designing, and Implementing Be-havioral Health Services (2005). 10. A Purchaser’s Guide to Clinical Preventive Services: Moving Science into Coverage (2006). Available at: http://www.businessgrouphealth.org. [Accessed Feb 17, 2015].

MARCH 2015 FEATURE 18

Filipino physicians provide appropriate initial management of patients diagnosed with acute coronary syndromeDR LEE EDSON P YARCIA

T he number one killer of Filipinos today are

cardiovascular diseases, but it is reassuring

to know that Filipino physicians are adhering to

the management guidelines for initial manage-

ment of patients with acute coronary syndrome

(ACS). In a multicenter descriptive study con-

ducted by Sinon and colleagues in 39 private

and government urban hospitals, physicians

at the ER were shown to comply with the 2007

American College of Cardiology/American Heart

Association (ACC/AHA) ACS guidelines for the

management of patients with unstable angina

(UA) /non-ST-segment elevation myocardial in-

farction (NSTEMI) and ST-segment elevation

myocardial infarction (STEMI). [Philipp J Intern

Med October-December 2014;52.]

A total of 1,398 eligible patients aged 18

years old and above were included in the study.

Up to 93 percent of patients had at least one car-

diac enzyme test done at the ER, with troponin

I being the most commonly requested. After di-

agnosis, 95.78 percent of patients received anti-

platelet therapy, the majority of whom received a

combination therapy of aspirin and clopidogrel.

As high as 98 percent of patients were then ad-

mitted in the hospital, while 26.68 percent were

considered to undergo percutaneous coronary

intervention.

The 2007 ACC/AHA guidelines recommend

obtaining an ECG and serum biomarkers for

patients presenting with classic symptoms of

ACS such as chest discomfort with or without

radiation to the arm, back, neck, jaw, or epigas-

tric pain. ECGs are important diagnostic tools

to provide management directions and clinical

prognosis. Biomarkers are important for estab-

lishing diagnosis. Cardiac troponins are the pre-

ferred markers because of their specificity and

sensitivity.

Moreover, the guidelines provide that man-

MARCH 2015 FEATURE 19

agement of UA/NSTEMI must be directed at

providing immediate relief of ischemia and pre-

vention of adverse outcomes. This is best ad-

dressed with anti-ischemic and anti-thrombotic

therapy. The guidelines suggest the use of aspi-

rin or a loading dose followed by a maintenance

dose of clopidogrel (300mg followed by a daily

dose of 75 mg). Patients who cannot tolerate

aspirin are given anticoagulant therapy such

as enoxaparin, bivalirudin or fondaparinux, and

this should be administered as soon as possible

after hospital admission. Invasive procedures,

such as percutaneous coronary interventions

may also be considered.

The study, published in the Philippine Jour-

nal of Internal Medicine, looked into records of

patients suspected of having ACS who were

brought to the ER. Seventy-six percent of pa-

tients were diagnosed with UA/NSTEMI, while

24 percent had STEMI confirmed with ECG and/

or cardiac enzymes results. Laboratory tests in-

cluded cardiac enzyme tests such as creatine

phosphokinase (CPK), CPK isoenzyme MB, tro-

ponin I and troponin T.

Upon diagnosis, more than 60 percent of

patients received combination of aspirin plus

clopidogrel, while 32.67 percent were started

with antiplatelet monotherapy. Aspirin was

given at a median total daily dose of 320mg,

while half of the total number of patients re-

ceived loading dose of clopidogrel. Around

86 percent of patients received anticoagulant

therapy, such as enoxaparin, fondaparinux, or

unfractionated heparin. Almost all the patients

(98 percent) were subsequently admitted

in the hospital, 66.03 percent of whom were

admitted in the critical care unit or intensive

care unit. Ninety one percent were referred to

a cardiologist, while 26.68 percent were con-

sidered to undergo percutaneous coronary

intervention.

The study shows that Filipino physicians,

across various specializations, use antiplatelets

and anticoagulants much frequently, in adher-

ence to the recent recommendations of the

ACC/AHA. This is important as medical organi-

zations or societies publish guidelines based on

best evidence to address the needs of patients.

The outcomes of patients presenting with ACS

are improved with adherence to generally ac-

ceptable approaches to diagnosis and manage-

ment.

“ ...it is reassuring to know that

Filipino physicians are adhering to

the management guidelines

for initial management of patients

with acute coronary syndrome”

MARCH 2015 FEATURE 21

A doctor-lawyer takes on medico-legal issues DR YVES SAINT JAMES AQUINO

D r Ivy Patdu remembered as a child that

she would say, depending on her mood,

she wanted to be a lawyer or a doctor, not know-

ing that in years to come she would actually be-

come both.

In 2002, Patdu graduated from the Univer-

sity of the Philippines-College of Medicine

(UPCM) under the Integrated Liberal Arts and

Medicine (INTARMED) program and got her

medical license that same year. Later on, Pat-

du would graduate from the Ateneo De Ma-

nila, School of Law and eventually passing the

bar after 2010.

“Most of the work I do actually involves both

medicine and law,” shared Patdu. At present, her

professional roles include being a legal consul-

tant for the Philippine Academy of Family Phy-

sicians, medico-legal officer for Asian Hospital

and Medical Center, and external consultant for

Legal Matters for the National Telehealth Center

in the University of the Philippines-Manila.

Idealism in childhoodAs a child, Patdu showed enthusiasm for

public speaking. To further develop her skills,

her father urged her to run for a position in the

Sangguniang Kabataan, the youth councils for

each barangay in the country. The original goal

was only to experience doing speeches during

the campaign period and to withdraw prior to

election day. There was a change of plan when

her family was told Patdu had a high chance of

winning. She stayed in the race and eventually

won a position as a councilperson.

“During this time, I was an idealist. I wanted

to fight for truth and justice,” wrote Patdu in one

of the personal essay she submitted during her

first year in law school. She explained that at the

time, her high-school classmates predicted that

she will become a lawyer and a human rights

advocate. “And so, I thought my purpose in life

was to be a lawyer,” she added.

While Patdu thought it was certain that she

would take up law in college, life offered another

alternative. She was accepted in the INTARMED

program of the UPCM, which allowed students

MARCH 2015 FEATURE 22

to finish medical school in seven years—two

years shorter than the more traditional track that

included four years of pre-med course and five

years of medical education. The program is also

deemed prestigious, accepting only 40 of the

best university applicants.

“The lure of the program was too big. As a

teenager, I became confused. Do I really want

to be a lawyer?” Patdu asked herself. She ex-

plained that she took this as a sign that she

needed to reconsider her original choice of tak-

ing up law.

With the support of her family, she realized

that being a doctor was much nobler than being

a lawyer, and that medical practice would allow

her to directly serve the people.

A period of introspectionBy the time Patdu was in the first year of med-

ical school proper (third year for the INTARMED

program), she started having serious doubts

about her academic track. She shared that one

of the organizations she joined was the UP Ma-

nila Debate Circle, making her realize that her

original passion for speaking and argumenta-

tion outweighed her interest to heal. Unlike her

zeal for philosophical and political debates, she

expressed disdain in having to study the anato-

my and physiology of the human body.

Despite her strong intentions to quit, she

decided to finish medicine and even enter a

residency program under the Department of

Otorhinolaryngology in the Philippine General

Hospital.

“Finally, during residency and after giving

medicine a try, I really was not happy,” added

Patdu.

After a period of introspection and inspired

reading of M. Scott Peck’s The Road Less Trav-

eled, Patdu decided to go to law school. “For

a year, I thought about it constantly and final-

ly I decided that I had to give my old dream a

chance,” wrote Patdu.

A combined practiceFew months after passing the bar examina-

tions in 2010, she started working as an associ-

ate lawyer in Solicitor General Estelito P. Men-

doza’s eponymous law firm. Patdu considers

Mendoza, a graduate of UP College of Law, as

her “mentor and inspiration.”

In her essay, Patdu cited Mendoza as an im-

portant example when she was convincing her

parents to allow her to go to law school. She

shared that the Solicitor General initially took a

pre-med course as an undergraduate but was

unhappy, eventually taking up law and becom-

ing one of the most celebrated lawyers in the

Philippines.

In the law firm, Patdu share that she was able

to realize her dream. She found her tasks inside

the courtroom the most challenging and also

the most enjoyable.

She admitted that working in the court did

not mean that she has stopped practicing medi-

cine, adding that her medical background helps

her a lot in her current work. Even as a law stu-

dent, she was naturally drawn to legal issues in

medicine. During her last year in Ateneo Law,

she wrote her juris doctor paper on “Hospital

Liability,” which received the dean’s award for

best thesis.

MARCH 2015 FEATURE 23

She also acknowledged that her medical

training taught her compassion, as well as

the value of hard work and perseverance. She

shared that it prepared her to accept that real

work would sometimes mean that you only get

a few hours of sleep. Patdu also explained it

taught her that learning is a life-long process,

which is important in both medicine and law as

the body of knowledge is quite dynamic, ever

changing and expanding.

In return, she also finds her legal back-

ground influencing her medical perspective.

Patdu admits that there are a lot of opportu-

nities to improve the medical practice in the

Philippines.

“The Medical Act of 1959 can be amend-

ed to be more responsive to current medical

practice,” shared Patdu. The medical act, also

known as Republic Act No. 2382, was meant

to establish standardization and regulation

of medical education, examination, licensure

and control of the practice of medicine in the

Philippines. A senate bill, known as the Physi-

cian’s Act of 2013, introduced by Senator Jing-

goy Ejercito Estrada is meant to upgrade the

medical act.

“Laws can be passed that promote a culture

of patient safety, and ways to improve hospital

processes to prevent or reduce medical errors,”

added Patdu.

Moving forwardAfter three years in the law firm, Patdu decid-

ed she needed to cut her work hours to take care

of her family, especially her two young children.

“I have assisted in controversial cases and

have learned valuable lessons while work-

ing there,” said Patdu. However, she said she

would prefer to start her own practice in order

to manage her own time and work closer to

home.

Last year, along with two other doctor-law-

yers, Patdu established the Patdu, Dimatatac

& Erfe Law Office in Muntinlupa City. “I’m still

learning .... The law practice is different in your

own firm versus being an associate in a law of-

fice,” expressed Patdu.

Despite her unorthodox and challenging

academic path, Patdu explained that she had

no regrets.

“Life is a journey,” said Patdu, emphasizing

the importance of exploring their options when

they are uncertain of they want to be or do in

life. “I think in the end, we all want to be happy,

and if your happiness is not in being a medi-

cal practitioner in the traditional sense, then

you deserve the chance to try and find it,” she

concluded

MARCH 2015 FEATURE 24

The Ludan method of hydration and other innovations: Dr Ludan’s legacy to pediatrics

DR MARIA KATRINA FLORCRUZ

D r Arturo Ludan’s journey started with a

single step that has treaded through a

thousand miles towards his goal of leaving a

lasting legacy to Philippine pediatric health-

care. An emeritus fellow of the Philippine Pedi-

atric Society (PPS) and recipient of numerous

awards, including The Outstanding Young Men

in 1977 and PPS Outstanding Pediatrician of

the Year 2014, he is well-known for his ground-

breaking work on diarrheal dehydration thera-

py and for coming up with the Ludan method

of hydration.

The first critical stepLudan’s pediatric practice has spanned

over 45 years. He is a graduate of the College

of Medicine – University of the Philippines (UP)

and completed his internship and first year of

pediatric residency at the Hospital of St Raphael

in New Haven, Connecticut.

“I took the first critical step when I took up pe-

diatrics… you have to make that career-defining

choice. Ano bang gusto mo talaga? Take pedi-

atrics and follow it through. In the process, try to

make your own skills, motivation and values,”

said Ludan.

He completed his training at Montefiore Hos-

pital and Medical Center in Bronx, New York

where he served as chief resident during his se-

nior year. It was in this same institution where

he met his mentor Dr Laurence Finberg, a world

renowned fluid and electrolyte physiologist.

Ludan recognizes the influence of Finberg on

his interest in pediatric fluid therapy. “I owe it to

him… I would not have been exposed to it [if not

for him]. “

Dr Arturo Ludan.

MARCH 2015 FEATURE 25

“As my mentor in Montefiore Hospital, he

taught me the tenets of fluid therapy which be-

came my subspecialty in pediatrics. That led me

to develop a simple and practical guide on fluid

therapy for maintenance, diarrheal dehydration

and dengue fever – the centerpiece of my lega-

cy to pediatric medicine,” he said.

Practical guide to fluid therapyHe returned to the Philippines in 1968 and

started his private practice with Capitol Medi-

cal Center. As an academician, he joined the

Department of Pediatrics of the UP-Philippine

General Hospital as clinical instructor and the

University of the East-College of Medicine as

professional lecturer.

He continued his work in fluid physiology and

was active in giving lectures on pediatric fluid

therapy of diarrhea, which would be later on rec-

ognized as the Ludan method.

The Ludan method of hydration calculates the

total fluid requirement per day of a child based

on body weight and is widely used by many phy-

sicians in treating dehydration due to diarrhea.

The fluid therapy includes the three therapeutic

phases – deficit, maintenance and replacement.

The deficit therapy corrects abnormal fluid

and electrolyte losses. Phase two or mainte-

nance therapy provides the daily normal losses

of fluid and electrolytes due to caloric expendi-

ture. Replacement therapy replenishes continu-

ing ongoing fluid losses due to conditions such

as vomiting and diarrhea.

The ORS formulationLudan also made notable contributions in the

improvement of the Oral Rehydration Solution

(ORS) in the Philippines when it was first intro-

duced by the WHO as oresol in the 1970s. “I

was hoping that the DOH will come out with the

right ORS. Oresol was the one with high sodi-

um, high osmolarity… I objected because I said

this [was] not safe for babies,” Ludan explained.

In 1978, while serving as the chairman of

the PPS Committee on Rehydration, he drafted

a position paper on the WHO oral rehydration

formulation, reiterating the concern on hyper-

Dr Ludan (left) during the awarding ceremonies for PPS Outstanding Pediatrician of the Year 2014, pictured here with one of his mentors, Dr Luis Mabilangan.

MARCH 2015 FEATURE 26

natremia and hyperosmolarity and suggesting

lowering the sodium level. “This position paper

was signed by the members of the PPS Board of

Trustees and was eventually forwarded to WHO

in Geneva,” said Ludan.

Thereafter, Ludan continued to give lec-

tures and workshops to promote the concept

and practice of oral rehydration therapy to

medical practitioners. He actively participated

in international fora on nutrition and diarrheal

diseases. He is also the author of several pub-

lications and wrote the chapter on fluid therapy

for the Philippine Textbook of Pediatrics and

Child Health, with Dr Fe del Mundo as the main

author.

Believing that the practice of medicine is a

dynamic process, Ludan continued his inter-

est in fluid and electrolyte therapy by develop-

ing a stepwise fluid management for dengue

fever (DF) and dengue shock syndrome (DSS).

In 2012, portions of this method were included

in the PPS-DOH National Guidelines in the fluid

management of DF/DSS.

Taking the road less travelledHe further ventured into the “road less trav-

elled” by being one of the first pediatricians to

integrate nutraceuticals, such as zinc and probi-

otics, in the management of diarrhea and atopic

dermatitis. “I want to develop my own method

and style of doing my practice… because of

these innovations, I was probably one of the

firsts to pioneer the use of probiotics,” said

Ludan.

He developed his interest in medical entre-

preneurship when he established the biologi-

cals distributor company Pedia-Aids, Inc. After

several years, he founded the pharmaceutical

company Pedipharma, Inc which specializes in

zinc preparations, saline nasal drops and nutra-

ceuticals.

Quality healthcare for allLudan thinks that there is a need to provide

medical coverage for all sectors of the society.

However, he also stressed the importance of

giving quality care.

“The intention of [the] government is to pro-

vide universal coverage… that’s in terms of the

quantity of healthcare. As to the quality of health

care, it’s a dynamic process because before we

can really achieve quality care, it requires train-

ing. These residents and practitioners should

adapt to high standards… And this is where the

PPS and other [medical] societies are involved...

the clinician is only as good as the training pro-

gram that he came from. If you come from an

institution that fails to comply with the standards

of care, then the quality of these practitioners

will suffer also,” said Ludan.

“It’s now up to the individual clinician to pos-

sess the qualification, the motivation and the

Dr Ludan with his wife, children and grandchildren.

MARCH 2015 FEATURE 27

values that are necessary to deliver these qual-

ity services. You have to possess the right at-

titude from the start. We [may] have everything

in place but if the clinician is not up to that, wala

din,” he added.

Recognizing mentorsLudan advises young doctors to follow the

mantra “A journey of a thousand miles begins

with a single step.”

“You have to start with an act which will guide

your career path. Take the road less travelled.

Be different but do not be indifferent to chang-

es. Do not follow the crowd. Create your own

career path and let others follow you. Develop

your own unique style of being an astute holistic

clinician,” he stated.

Moreover, he encourages doctors to be in-

quisitive, innovative, creative and research-

minded. “You don’t get fossilized and stunted

by what you learn in residency… you have to

continue enhancing, updating, improving,” said

Ludan.

Ludan reminds doctors who eventually be-

come successful to always look back. “Remem-

ber your mentors and role models. When I got

my PPS Outstanding Pediatrician [of the Year]

award, I recognized my mentors.”

“Dr Ludivina Garces-Holst, during my residen-

cy, instilled the importance of the right attitude.

Dr Finberg provided the knowledge and exper-

tise in fluid pediatrics. Dr Luis Mabilangan was

the epitome of love for teaching. Dr Perla San-

tos-Ocampo is a trailblazer of child advocacies.

Dr Fe del Mundo showed me that one should go

beyond one’s borders of comfort zone and serve

the community. Lastly, Dr Lino Ed Lim showed

me that to be an active pediatrician and at the

same time a business entrepreneur was doable,”

he said.

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Many more distinguished overseas speakers to follow…

MARCH 2015 MARKET WATCH 29

Nutrilite stages health run

Capping its 80th anniversary celebration,

Nutrilite, the global health supplement

brand, held last MARCH 22 the Philippine leg of

the Nutrilite Health Run, a regional initiative ad-

vocating healthy living. The run already covered

Indonesia, Malaysia, Vietnam, Thailand, Austra-

lia and Singapore.

“Wellness has always been the Nutrilite ad-

vocacy ...Through this series of runs, we want

to encourage more people to put a premium

on their personal wellness,” said Leni Olmedo,

Country Manager of Amway Philippines, distrib-

utor of Nutrilite products.

The run kicked off at the Blue Bay Walk in Pa-

say City. The

run kit includ-

ed, among

others, Am-

way Expo ac-

cess stubs,

free member-

ship in Am-

way and a raf-

fle entry. Leg 2 of the race will be held on March 1,

2015 in Davao City. Leg 3 will be on March 15, 2015

in Cagayan de Oro City. Proceeds of the run will

go to the Amway One by One Campaign for

Children.

Philippine Heart Center holds cardiovascular intervention summit

In line with the 40th year celebration of the

Philippine Heart Center (PHC), its scientific

committee conducted a “Cardiovascular Inter-

vention and Innovation Summit” last MARCH

23 at the Dr. Avenilo Aventura Hall. Dr. Dy Bun

Yok, considered the father of interventional car-

diology in the Philippines, delivered the key-

note address on the historical development of

cardiovascular intervention.

The aim of this forum was to update the

knowledge of general cardiologists, inter-

nists, surgeons and cardiovascular tech-

nologists/technicians in the interventional

approach to the management of common

cardiovascular diseases. The various inter-

ventional pro-

cedures and

innovations cur-

rently available

for the manage-

ment of patients

with diverse

c a rd i o v a s c u l a r

disorders were

presented. This

summit also showcased the pioneering ef-

forts and achievements of PHC and its car-

diovascular specialists, and the Filipino

patients who benefited from these services.

Registration was free.

MARCH 2015 MARKET WATCH 30

PhilHealth conducts 2nd nationwide, simultaneous runs

I n celebration of PhilHealth’s 20th year in

MARCH 2015, PhilHealth successfully staged

a simultaneous run in NCR, Luzon, Visayas and

Mindanao primarily to promote and advocate

the benefits and it provides to its members. The

run’s carrier theme was the primary care ben-

efit package offered by PhilHealth or “TSeKaP”

(“Tamang Serbisyo para sa Kalusugan ng Pami-

lya”) to instill among target participants, particu-

larly those in the vulnerable sectors of society,

the importance of having a first line of defense

against costly hospitalization. Thus, the run is

dubbed “PhilHealth: Ready, TSeKaP, Go!”

At the same time, the run was intended to

showcase the

c o m p a n y ’ s

advocacy of

se l f l essness

as an organi-

zation, of in-

stilling gener-

HCWH-Asia joins first Zero Waste Fair

H ealth Care Without Harm-Asia (HCWH-

Asia), part of a global organization trans-

forming the health care sector through anti-in-

cineration advocacy and the promotion of green

and healthy hospitals, participated in the first

Zero Waste Fair, a highlight of the Zero Waste

Month. The exhibit was held from January 22

to24 at the Quezon Memorial Circle, Quezon

City.

HCWH showcased at the fair the successes

of three Philippine member-hospitals of Global

Green and Healthy Hospitals, a global cam-

paign of HCWH that represents the interest of

more than 9,700 hospitals and health centers

from six continents

that are committed

to reducing their

ecological footprint

and promoting en-

vironmental health.

The three hospitals,

the Philippine Heart

Center of Quezon City, St Paul Hospital-Tugueg-

arao and Maria Reyna Xavier University Hospi-

tal of Cagayan de Oro, exhibited their best prac-

tices to encourage other health care institutions

to implement proper health care waste manage-

ment.

osity, of welcoming every opportunity to share

resources for the improvement of the plight of

others.

The Philippine Health Insurance Corpo-

ration or PhilHealth was created in 1995 to

create a universal health coverage for the Phil-

ippines.

MARCH 2015 MARKET WATCH 31

The Medical City offers transradial catheterization

AstraZeneca Philippines forms coalition of medical specialists to fight cancer

A t The Medical City (TMC), interventional

cardiologists had utilized femoral artery

as the preferred route for coronary procedures

in the past years. The radial artery default ac-

cess for angiography and coronary intervention

at TMC was started in April 2010 by TMC con-

sultants Drs Sabas and Paolo Prado and since

then, has become the preferred access for coro-

nary procedures by most of the interventional

cardiologists.

Dr. Sabas cited the benefits of transradial

catheterization, which includes a lower risk of

bleeding at the incision site, less risk of ma-

jor complications

that require blood

transfusion or

surgery, and less

hematoma forma-

tion after the pro-

cedure. Transradial patients can move around

and walk to the bathroom after the procedure.

In the Philippines, TMC is one of the

first hospitals to offer transradial catheter-

ization. TMC Cath Lab currently uses tran-

sradial access in almost 90 percent of its

coronary procedures.

O NCOalition, created with the help of Aztra-

Zeneca, held its inaugural CME activity re-

cently at The Medical City hospital in Pasig City.

Involving cancer specialists and scientists, the

dinner symposium was entitled “The Future of

Oncology, Personalized Treatment and Patient

Care.” The coalition aims not only to recognize

current unmet needs in the optimal diagnosis

and treatment of leading cancer types such as

breast and lung cancers among Filipinos, but

also to emphasize the importance of biomarkers

and pioneering therapies.

AstraZeneca is privileged to partner with Fili-

pino cancer specialists in achieving our shared

goal of redefining cancer treatment, restoring

patients’ lives and eliminating cancer as a cause

of death,” said Gagan Singh, country president

of AstraZeneca Philippines.

“For 2015, ONCOalition will hold a series of

follow-up scientific discussions and major sym-

posia,” said Joshua Valencia, senior brand man-

ager, AstraZeneca Philippines.

Professor Richard L. PrinceSchool of Medicine and PharmacologyUniversity of Western AustraliaSir Charles Gairdner HospitalPerth, Western Australia

Bone fractures are the result of the interaction between external forces on the bone (e.g. falls), and the inherent bone strength. The integrity and strength of bone is maintained by the bone resorption-formation cycle, which regenerates the skeleton every 5 to 10 years. The decrease in bone mass and density characteristic of osteoporosis is a result of the gradual loss of cortical bone through net resorption. This deterioration can lead to an increased risk of fractures. One way to counter this deterioration is through calcium and vitamin D supplementation, which have favourable effects bone density and skeletal outcomes, particularly in elderly women.1-8

The role of calcium supplementationInitially, it was hypothesised that osteoporosis was a protein disorder, wherein osteoblasts fail to produce bone matrix. However, subsequent studies concluded that calcium-deficiency was an important factor in the development of osteoporosis leading to poor bone mineralisation and micro-anatomical deterioration.1

A 2-year randomised, placebo-controlled study has demonstrated that calcium supplementation can help reduce age-related bone loss in post-menopausal women.2 In the study, the subjects were randomised to receive one of four interventions: placebo, milk powder containing 1,000 mg of calcium, calcium tablets (1,000 mg/night), and calcium tablets (1,000 mg/night) plus an exercise regimen. Bone mineral density (BMD) at the lumbar spine, three hip sites, and two sites of the tibia close to the ankle joint were measured at 6-month intervals.

After the 2-year follow-up, it was found that calcium supplementation by either calcium tablets or milk powder prevented bone loss at the intertrochanteric hip site. Those who received placebo, calcium tablets, calcium and exercise, and milk powder reported a BMD percent-change of -0.81%, 0.17%, 0.23%, and 0.07% per year, respectively (p < 0.05 for all supplementation groups compared with placebo).

Synergy with vitamin DCalcium deficiency is not the only common nutritional deficiency that causes brittle bones. During the turn of the 20th century, rickets was a common problem especially in Europe. Rickets was later revealed to be a vitamin D-deficiency disorder. Osteomalacia, a similar disorder in adults (after epiphyseal closure), is characterised by poor bone mineralisation and is also mainly caused by vitamin D deficiency.3

Currently, the role of vitamin D in bone mineralisation is believed to be through promotion of gut calcium absorption, leading to an increase in extra-cellular calcium, a decrease in parathyroid hormone (PTH) levels, and a resulting decrease in bone resorption. The National Health and Nutrition Examination Survey (2004) revealed that an increase in serum 25-hydroxyvitamin D from 25 to 60 nmol/L was accompanied by a 5% increase in BMD.4 In contrast, in patients with low serum 25-hydroxyvitamin D, subclinical osteomalacia was commonly found by iliac crest bone biopsy.5

Evidently, the roles of calcium and vitamin D in promoting positive bone mineral balance are complimentary. A 5-year randomised, controlled, double-blind trial on 120 community-dwelling women aged 70 to 80 years was conducted to evaluate the effect of vitamin D added to calcium supplementation on hip BMD and other calcium-related parameters.6 Patients were randomised to receive one of three interventions: 1,200 mg/day of calcium with placebo; 1,200 mg/day of calcium plus 1,000 IU/day of vitamin D2; or double placebo (control). After the 5-year follow-up, only patients on calcium plus vitamin D supplementation had significantly better maintenance

of hip BMD compared with control (Table 1). Furthermore, combined supplementation reduced PTH at Year 3 and 5 vs control (p<0.005) in patients with baseline PTH levels above the median (3.6 pmol/L).

The positive effects of combined calcium and vitamin D supplementation translate to relevant patient outcomes. It has been demonstrated that in patients with a history of falling and vitamin D insufficiency living in sunny climates, vitamin D supplementation added to calcium was associated with a 19% reduction in the relative risk of falling, mostly during winter.7 Similarly, a randomised controlled trial showed that supplementation for 18 months with 1,200 mg of elemental calcium combined with 800 IU of vitamin D3, given to healthy ambulatory women living in nursing homes with a mean age 84 years , reduced the number of hip fractures by 43% (p=0.043), and the number of non-vertebral fractures by 32% (p=0.015) vs those on placebo.8 Furthermore, the incidence of hip fractures increased over time among those who received placebo, but remained stable in those who received calcium and vitamin D (Figure 1).

These results strongly indicate that calcium and vitamin D supplementation, especially in elderly women or others at high risk of osteoporosis, falls, or fractures, is beneficial in improving BMD and preventing adverse skeletal outcomes.

Calcium and cardiovascular riskDespite these demonstrated benefits, there is hesitation in some clinicians to actively recommend calcium supplementation. One of the main concerns arose from a 2008 randomised controlled trial suggesting that women on 1,000 mg of elemental calcium supplementation for 5 years had an increased risk of myocardial infarction (MI).9 However, it should be noted that the Kaplan-Meyer curve on time-to-first MI reported a p-value of 0.14 using log-rank test comparison.

A recently published study aimed to clarify the mechanisms underlying calcium-associated cardiovascular risk, particularly on its effect on atherosclerosis, the primary lesion associated with MI. This was an ancillary study of the Calcium Intake Fracture Outcome Study (CAIFOS) that evaluated the benefit of 5-year supplementation of 1,200 mg of elemental calcium. The ancillary study assessed common carotid artery intimal medial thickness (CCA-IMT) and carotid atherosclerosis at Year 3.10

Results of this ancillary study revealed that the multivariable-adjusted mean CCA-IMT of women randomised to calcium supplementation were not significantly different from women who received placebo.10 Furthermore, women who received calcium supplementation did not have increased carotid atherosclerosis (47.2% vs 52.7% with placebo; p=0.066) (Table 2). Interestingly, those in the highest tertile of total calcium intake had reduced carotid atherosclerosis compared with those in the lowest tertile (adjusted OR 0.70 [95% CI 0.51-0.96]; p = 0.028). The study concluded that these findings do not support the hypothesis that calcium supplementation increases atherosclerosis, and may even reduce surrogate cardiovascular risk factors.

Finally, a recently published meta-analysis on randomised controlled trials evaluated the cardiovascular safety of calcium supplementation (with or without vitamin D supplementation).11 The meta-analysis included 63,563 participants, and revealed that calcium supplementation with or without vitamin D supplementation, did not significantly increase coronary heart disease events (RR 1.02; 95% CI 0.96, 1.09; p=0.51), all-cause mortality (RR 0.96; 95% CI 0.91, 1.02; p=0.18); and MI (RR 1.08; 95% CI 0.92, 1.26; p=0.32). Heterogeneity among the trials was low (I2 = 0%).

Unlike in clinical trials, a one-size-fits-all approach cannot be implemented in actual clinical practice. The management of a post-menopausal woman with low serum vitamin D would be different from that of a 30-year old woman with no known risk factors. Patients at greater risk should receive more proactive management.

In summary, calcium and vitamin D supplementation increases bone density, particularly in elderly women. This improvement translates to better skeletal outcomes by reducing fractures and falls in these patients. There is weak evidence behind concerns of increased cardiovascular risk associated with calcium supplementation. For those at high risk of adverse skeletal outcomes, calcium and vitamin D supplementation is warranted.

References: 1. Nordin BEC. Nutrition 1997;13:664–686. 2. Prince R, Devine A, Dick I, et al. J Bone Miner Res 1995;10:1068-1075.3. Bhan A, Rao AD, Rao DS. Endocrinol Metab Clin North Am 2010;39:321-331.4. Bischoff-Ferrari HA, Dietrich T, Orav EJ, Dawson-Hughes B. Am J Med

2004;116:634-639.5. Priemel M, von Domarus C, Klatte TO, et al. J Bone Miner Res 2010;25:305-312.6. Zhu K, Devine A, Dick IM, Wilson SG, Prince RL. J Clin Endocrinol Metab

2008;93:743-749. 7. Prince RL, Austin N, Devine A, et al. Arch Intern Med 2008;168:103-108.8. Chapuy MC, Arlot ME, Duboeuf F. N Engl J Med 1992;327:1637-1642.9. Bolland MJ, Barber PA, Doughty RN. BMJ 2008;336:262-266. 10. Lewis JR, Zhu K, Thompson PL, Prince RL. J Bone Miner Res 2014;29:534-541.11. Lewis JR, Radavelli-Bagatini S, Rejnmark L, et al. J Bone Miner Res 2015;30:165-

75.

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The Calcium and Vitamin D Controversy: an Update from the Endocrine AngleCalcium deficiency is an important factor in the development of osteoporosis. In a sponsored symposium supported by the International Osteoporosis Foundation and Pfizer Consumer Healthcare, Professor Richard L. Prince reviewed the evidence demonstrating the benefits of calcium and vitamin D supplementation on bone density and skeletal outcomes in the management of osteoporosis, and recent data confirming the cardiovascular safety of these interventions. The symposium was part of the International Osteoporosis Foundation Regional 5th Asia-Pacific Osteoporosis Meeting, held from 14 to 16 November 2014 at the Taipei International Convention Center, Taiwan.

Table 1. Effect of combined calcium and vitamin D supple-mentation on hip BMD and bone-related biochemistry (% difference vs control)6

Year 1 Year 3 Year 5

Hip BMD 1.2 ± 0.6% (p=0.04)

2.8 ± 1.1% (p=0.01)

2.2 ± 1.1% (p=0.05)

Plasma alkaline phosphatase concentration

-11.3 ± 2.9% (p<0.001)

-8.7 ± 3.9% (p=0.03)

-11.3 ± 5.7% (p=0.05)

Urinary deoxypyridinoline-to-creatine ratio

−34.5 ± 8.6% (p<0.001)

−16.3 ± 8.0% (p=0.05)

−27.6 ± 8.6% (p=0.002)

Plasma calcium concentration

1.8 ± 0.7% (p=0.01)

2.6 ± 0.8% (p=0.001)

NS*

BMD, bone mineral density; NS, not significant.*Data not published

Table 2. Intention-to-treat and per-protocol odds ratios for the presence of common carotid artery atherosclerosis according to randomization for calcium supplementation at baseline.10

Intention-to-treat

Placebo Calcium P-value

Unadjusted 1.0 0.80 (0.63-1.02) 0.066

Multivariate adjusted 1.0 0.80 (0.6-1.04) 0.095

Per protocol

Placebo Calcium P-value

Unadjusted 1.0 0.73 (0.54-0.97) 0.033

Multivariate adjusted 1.0 0.74 (0.54-1.02) 0.064

0

10

20

30

40

50

60

70

80

0-6 months 6-12 months 12-18 months

Placebo

Calcium + Vit. D

Incid

ence

(no.

/1,0

00/y

ear)

p=0.007

45 47

66

38 37 39

Figure 1. Incidence of hip fractures among elderly women treated with vitamin D plus calcium vs place-bo, according to length of follow-up.8

Dear Friends and Colleagues from the Region,

The time has come for us to convene for an update on ObGyn ultrasound. Please come join us at the 11th ISUOG-Outreach 2015 in Singapore, on Sunday 3rd May to Tuesday 5th May 2015. The venue will be a new iconic building for diagnostics, research and healthcare education – The Academia on Outram (Singapore General Hospital) Campus, 20 College Road.

The theme of this meeting is “Defining Contemporary Office Investigations – Closing the gap between ultrasound, laboratory tests and your practice”.

The past decade witnessed an explosion of science and medical knowledge surrounding the ObGyn practice. Many routine tests have gone molecular; point of service imaging has become very sophisticated; reports of tests utilising sophisticated bioinformatics algorithms land on our clinic desk daily. While some of these routine tests and imaging in our clinics are expensive and the technology intimidating, this meeting guides you to the tests best suited for your clinical needs.

We cordially invite you to come to this occasion where leading international speakers in the academic world reach out to the ObGyn communities in this region. Last year, the 10th ISUOG-Outreach 2014 has been socially and academically stimulating as we were joined by an excess of 550 delegates, 25 overseas and 42 local speakers, to celebrate the 10th anniversary of this meeting. The 11th ISUOG-Outreach is looking to be equally enriching. We hope to welcome many of you to Singapore come May 2015.

Yours Sincerely,

George SH YeoChairman

Tan Hak KoonCo-chairman

11th International Society of Ultrasound in Obstetrics & Gynecology Outreach Course (ISUOG-OR) 2015in conjunction with 6th Scientific Congress of College of Obstetricians & Gynaecologists, Singapore (COGS) 2015

Brought to you by

College of Obstetricians & Gynaecologists, Singaporeisuog.org

Defining Contemporary Office Investigations Closing the gap between ultrasound, laboratory tests and your practice3 – 5 May 2015The Academia @ Outram Campus (Singapore General Hospital) Singapore

Scan QR Code to visit event website

REGISTER ONLINE NOW AT www.isuog-or.comEnjoy Early Bird Rate from 1 Jan – 15 Mar 2015

Normal Rate applies thereafter. Hurry - registration closes on 14 Apr 2015BE PART OF THE 11th ISUOG-Outreach & 6th Scientific Congress of COGS 3 – 5 May 2015 @ The Academia on SGH Outram Campus, Singapore

…MORE TO COME – COME JOIN THE COURSE AS A LEADING FACULTY CONGREGATES HERE IN OUR REGION!Latest programme, updates and online registration at

www.isuog-or.com

BENOIT BernardFrance

CHAOUI Rabih

Germany

EVANS MarkUSA

HYETT Jon

Australia

MALINGER GustavoIsrael

JAPARAJ Robert Peter

Malaysia

MURAKOSHI TakeshiJapan

KIM Gwang Jun

Korea

LEUNG Kwok Yin

Hong Kong

POON Leona

UK

VILLE Yves

France

WON Hye Sung

Korea

SHIH JinchungTaiwan

SALOMON LaurentFrance

Invited Faculty of the 11th ISUOG-Outreach Course & 6th Scientific Congress of College O & G, Singapore 3 – 5 May 2015

MARCH 2015 NEWS 35

ICU patients may benefit from assistive communication toolsCHUAH SU PING

Half of patients in intensive care units

(ICUs) who are on ventilators to help them

breathe, could benefit from assistive communi-

cation tools, a new study has revealed.

In the study, 53.9 percent of the 2,671 me-

chanically ventilated patients screened met

basic communication criteria and could po-

tentially benefit from the use of assistive com-

munication tools and speech language con-

sultation. These tools could be as simple as

a notepad and pen that may allow a patient

to write requests and questions. Patients who

were eligible for the study were those who

were awake, alert and responsive to verbal

communication from clinicians for at least one

12-hour nursing shift, while receiving mechani-

cal ventilation (MV) for 2 or more consecutive

days. [Heart Lung 2015;44:45-49]

“Our findings challenge the commonly held

assumption of many clinicians and research-

ers that these patients are unable to communi-

cate or participate in their care,” said Dr. Mary

Beth Happ, co-author of the study, and distin-

guished professor of nursing at The Ohio State

University, Columbus, Ohio, US. The study,

which involved six specialty ICUs across two

hospitals in an academic health system found

that the lowest proportion of MV patients who

met communication criteria were from the Neu-

rological ICU (40.8 percent), while the highest

proportion was from the Trauma ICU (70 per-

cent).

“Establishing lines of communication is the

first step in a patient being able to make his

or her needs known and have accurate symp-

tom assessment and management, and con-

tributes to an overall better patient experience.

We know from interviews with patients who re-

member their critical care experience that the

inability to communicate is anxiety producing

and, in some cases, terrifying,” said Happ.

Dr. Augustine Tee, chief and senior consul-

tant at the Department of Respiratory and Criti-

cal Care Medicine at Changi General Hospital

(CGH), Singapore, agreed on the importance

of improving communication during critical

care. “As intensivists, we are now paying more

attention to avoid oversedation of mechani-

cally ventilated ICU patients, as research has

shown that a more awake and participative

ICU patient has a better prognosis in terms of

recovery,” he said.

“As such, for an ICU patient to be able to

interact with ICU staff via various communica-

MARCH 2015 NEWS 36

tion aids is a natural development accompany-

ing reduction in sedative medication use,” said

Tee. He highlighted that CGH utilises innova-

tive assistive communication tools in its ICUs,

such as the award winning ICU Patient Care

Communicator App which has various features

to help patients communicate with caregivers

and family members.

Using an electronic tablet that is brought

bedside, patients are able to use the app to

indicate via words and pictures, their physical

and emotional needs. The app also enables

patients to communicate by sketching or writ-

ing simple words. Additionally, the app in-

cludes a pain management chart which allows

patients to convey the level of pain they are

experiencing in various parts of their body. The

app, which features translation capabilities in

19 different languages, was developed by the

Society of Critical Care Medicine (US). [The

Society of Critical Care Medicine; ICU Patient

Communicator App. Available at www.sccm.

org/News/Pages/ICU-Patient-Communicator-

App.aspx. Accessed on 27 January 2015]

MARCH 2015 NEWS 37

Excess body weight linked to higher risk of cancerCHUAH SU PING

High body mass index (BMI), defined as 25

kg/m2 or greater, is associated with an in-

creased risk of cancer, according to a study in-

volving data from 184 countries.

According to the population-based study,

481,000 or 3.6 percent of all new cancer cases

in adults in 2012 were attributable to high BMI.

Population attributable fractions (PAFs) were

greater in women than in men (5.4 versus 1.9

percent). Corpus uteri, postmenopausal breast

and colon cancers accounted for 63.6 percent

of cancer attributable to high BMI. The investi-

gators also noted that a quarter (approximately

118,000) of the cancer cases related to high BMI

in 2012 were probably due to the increase in

BMI since 1982. [Lancet Oncol 2015;16:36-46]

“Data from Singapore were analysed as

part of the Southeast Asia geographic region.

Overall, the risk of obesity-associated cancer is

somewhat lower in Southeast Asia compared

with the global average,” said Dr. Wong Seng

Weng, medical director and consultant special-

ist in medical oncology at The Cancer Centre

(a Singapore Medical Group Clinic). He noted

that globally, obesity contributed to 1.9 percent

of newly diagnosed cancer in men and 5.4 per-

cent in women. “The corresponding figures for

Southeast Asia were 0.5 percent for men, and

2.2 percent for women.”

“The reason for this difference is that North

America and Europe have higher incidences of

high BMI and are responsible for two-thirds of

the global incidence of obesity-related cancers,”

said Wong. However, the rise in obesity rate has

slowed in North America but continues to rise in

regions such as Southeast Asia. In other words,

while Singapore with other Southeast Asian

countries is in a better position today than North

America, our advantage is likely to erode over

the next decades.”

Wong noted that this study is important as it

showed the huge cancer burden, with half a mil-

lion of new cases yearly contributed by obesity.

“On top of that, it demonstrated a trend – the in-

cidence of being overweight has increased by

about a quarter worldwide over the last three de-

cades. This effect alone has contributed 120,000

new cases of cancer yearly worldwide. This trend

is going to accelerate with globalisation and

economic development in the developing world

where the bulk of the world population reside.”

Obesity plays a promoting roleWith regards to how obesity contributes to

MARCH 2015 NEWS 38

cancer risk, Wong noted that it is unlikely that

obesity by itself initiates the process of carcino-

genesis. “Rather, obesity plays a promoting role,”

he said. “Excess body weight has been associ-

ated with an increase in oestrogen as adipose

tissue contains an enzyme known as aromatase,

which is responsible for aromatising circulating

androgen in the body into oestrogen. Several

cancers in women such as breast cancer and en-

dometrial cancer are known to be related to the

stimulation by oestrogen.”

“An excess body weight also increases the

body’s resistance to the effect of insulin in the reg-

ulation of serum glucose level. Excess produc-

tion of insulin and related substances known as

insulin-like growth factors promotes cell growth

including cancer cells,” said Wong.

Wong noted that while patients who have not

suffered from cancer should be counselled on

appropriate weight management (if they are over-

weight), it is important to also educate patients

and their families that the weight issue should not

be tackled during the acute phase of anti-cancer

therapy. “During cancer treatment, paradoxically,

measures are necessary to prevent excessive

weight loss leading to weakening of the body and

compromising the patient’s ability to complete

the prescribed treatment course.”

“For certain cancers, for instance breast can-

cer in post-menopausal women, factors such as

obesity, high fat and low fibre diets, and a lack of

exercise are constantly associated with a higher

risk of relapse following potentially curative treat-

ment in clinical studies,” said Wong.

MT(PH-REG)MAR2015-FINAL.indd 18 24/2/15 3:38 pm

• EFFECTIVE and WELL TOLERATED• TARGETS PAIN and INFLAMMATION

• EFFECTIVE and WELL TOLERATED • TARGETS PAIN and INFLAMMATION •

MARCH 2015 NEWS 39

Chronic fatigue syndrome redefinedJENNY NG

A committee report on chronic fatigue syn-

drome developed by the US Institute of

Medicine (IOM) is hoping to educate physicians

on the seriousness of the condition with a new

name and new diagnostic criteria.

The committee suggested renaming chronic

fatigue syndrome as systemic exertion intoler-

ance disease (SEID) to more accurately reflect

the complexity of the condition. To receive a di-

agnosis of SEID, patients would have to have

each of the following four symptoms:

1. A substantial reduction or impairment in

the ability to engage in pre-illness levels of oc-

cupational, educational, social, or personal ac-

tivities that persists for more than 6 months and

is accompanied by fatigue, which is often pro-

found, is of new or definite onset (not lifelong), is

not the result of ongoing excessive exertion and

is not substantially alleviated by rest;

2. Postexertional malaise;

3. Unrefreshing sleep; and

4. Cognitive impairment or orthostatic intoler-

ance

“Our goal is to facilitate diagnosis,” said

Committee Chair Dr. Ellen Clayton of the

Vanderbilt University, Nashville, TN, US. “We

hope these evidence-based diagnostic cri-

teria provide a new foundation for future re-

search regarding cause and treatment.”

The report was commissioned by the US

Department of Health and Human Services,

National Institutes of Health, US Social Secu-

rity Administration, US FDA, US CDC, and the

Agency for Healthcare Research and Quality

to develop evidence-based clinical diagnostic

criteria for SEID for use by clinicians.

One difficulty in diagnosing SEID is the yet

unknown aetiology of the disease. Diagnosis

is therefore based on the identification of core

symptoms, the most prominent being exces-

sive postexertional fatigue that can severely

limit a person’s ability to function in day-to-

day life.

According to Clayton, these symptoms

can often be met with skepticism from physi-

cians. However, the panel found compelling

evidence for impairment, especially in the

characteristic decrements seen after 2-day

cardiopulmonary testing, the clear and re-

producible findings of orthostatic intolerance,

and evidence of slowed processing based on

neuropsychiatric test data.

The committee further detailed an algo-

rithm for diagnosis, providing an extensive list

of findings on patient history, physical exami-

nation, and symptom-based tests, to be used

along with the new criteria.

“We emphatically do not want clinicians to

do all the objective tests we identify. They’re

MARCH 2015 NEWS 40

expensive, onerous, and not uniformly avail-

able,” noted Clayton. “Often you can get most

of what you need from the history and physi-

cal examination.”

Symptom-based treatment is recommended

to begin as soon as the symptoms are identi-

fied. Committee member Dr. Peter Rowe of the

Johns Hopkins Children’s Center in Baltimore,

MD, US, added, “We’ve got good treatment al-

gorithms for things like headaches, sleep dis-

turbance, and certain [other] kinds of pain. No

one treatment is appropriate for every person,

but there’s much out there that’s helpful and

available [to clinicians].”

Comparisons in the treatment of heel painAn expert in Sports and Rehabilitation Medicine discussed modalities in the

treatment of athletic injury during the 4th Asia-Oceanian Conference of Physical

and Rehabilitation Medicine, held at the Plaza Athenee in Bangkok, Thailand,

last December 12, 2014.

Sports injuries in the Philippines comprise

36% of trauma seen daily in the ER. There

is an equal distribution across age groups.

As people are becoming more athletic, more

injuries may also happen.1 Sports injuries

among those 65 and older have increased by as

much as 50 percent in the last 20 years. Among

people 75 and older, sports-related injuries in-

creased by 29%.2

Most injuries are characterized by heel pain,

it is experienced by 85-90% of the population.

This heel pain may be calcaneal tendonitis and/

or plantar fasciitis patients, with only 30% of

patients having no athletic activity. Tendinopa-

thy is common among athletes participating in

racquet sports, track and field, volleyball and

soccer. However, the condition may also be ex-

perienced by non-athletes. The basic symptom

of tendinopathy is pain. It usually occurs at the

commencement and end of a training session.

Pain may also occur during exercise, as pathol-

ogy progress, even interfering with activities of

daily living. There may be an acute phase, when

the tendon is diffusely swollen and tenderness

on palpation is usually greatest 2–6 cm proxi-

mal to the tendon insertion. There may also be

palpable crepitations. A tender, nodular swell-

ing may be commonly present in chronic cases

signifies tendinosis. Diagnosis of tendinopathy

is based mainly on history and detailed clinical

examination. However, diagnostic imaging may

be requested to exclude other musculoskeletal

disorders. Conservative management with oral

or topical anti-inflammatory medications is em-

ployed. Physiotherapy and stretching exercises

Prof. BFD Valdecanas

MEETING HIGHLIGHTS 42

are also usually done.1

Research on different methods of enhancing

transdermal delivery of specific drugs aimed

for systemic and/or local effect. The main goal

was to facilitate absorption from the skin to the

site of pain.3 One of these many methods of

transdermal medication delivery is phonopo-

resis. It is used in pain and anti-inflammatory

management by employing ultrasound waves

to enhance fast absorption of therapeutic sub-

stances through the skin. In phonoporesis,

special sound waves above the audible limit of

20kHz are utilized.4

Literature is not lacking about the use of ul-

trasound for better delivery of medications. Gel-

based substances showed 80% better absorp-

tion, compared with water-based preparations.4

Examining effects of ultrasound in the clinical

setting,5-8 results showed ibuprofen with phono-

poresis and plain ultrasound were both effec-

tive in 10 sessions.6 Ketoprofen with ultrasound,

showed increased level of ketoprofen in the

non-fatty tissue of the knees (synovium) com-

pared with serum levels. Subcutaneous tissues

may serve as a reservoir of ketoprofen.7,8

A double-blind, multi-operator, single-

center prospective study was done with 150

participants to compare the efficacy of ke-

toprofen phonophoresis and conventional

plain ultrasound in the treatment of heel pain.

Pulse therapy was used. Improvement in

functional assessment scores was obtained

from pre-treatment questionnaire to post-

treatment survey.9 Improvement in pain per-

ception was also measured using the visual

analog scale (VAS).10 The participants who

were included in the research had the follow-

ing characteristics: diagnosed with calcaneal

tendonitis, plantar fasciitis, or both; has uni-

lateral affectation; without nerve entrapment

syndromes; without post-traumatic arthri-

tis; without hypersensitivity to ketoprofen or

other non-steroidal anti-inflammatory drugs.11

Results demonstrated that VAS scores

were improved in the phonophoresis group.

(Figure 1) Moreover, results showed that ke-

toprofen has triple action effect. There was

faster absorption and superior diffusion of the

Figure 1. Graph of VAS scores per treatment session

90

67.5

45

22.5

0

Treatment 1 Treatment 2 Treatment 4 Treatment 6 Treatment 8

Ketoprofen Phonophoresis Plain Ultrasound

VAS Scores(0-100mm)

Figure 2. Graph of scores in Functional assessment

100

75

50

25

0Ambulation ADLs Sports Total

Functional Scoring(FAAM)

Ketoprofen Phonophoresis Plain Ultrasound

MEETING HIGHLIGHTS 43

active substance at the inflammation site. This

may be due to ketoprofen being concentrated

in the synovium, more than in fatty tissue and

serum, after phonophoresis.12 There was also

high tissue concentration level only at the pain

site, thus minimizing systemic side effects.

Even functional assessment scores showed

improvement in the ketoprofen phonophoresis

group.10 (Figure 2)

With the results, it is recommended that fur-

ther analysis of data may be done (i.e., differ-

ence in response between males and females,

specific diagnoses and response to intervention

may be scrutinized). Furthermore, additional

subsets may be included (e.g., ketoprofen gel

application with sham ultrasound). Serum level

References: 1. Maffulli N, et al. J R Soc Med 2004;97:472–476. 2. Annual Cen-sus, Cardinal Santos Memorial Medical Center. 2014. 3. Byl NN. Phys Ther 1995;75(6):539-53. 4. Cameron MH, et al. Phys Ther 1992;72(2):142-8. 5. Klaiman MD, et al. Med Sci Sports Ex-erc 1998;30:1349-1355 6. Kozanoglu E, et al. Swiss Med Wkly 2003;133(23-24):333-8. 7. Rolf C, et al. J Rheumatol 1997;24(8):1595-8. 8. Coaccioli S. Eur Rev Med Pharmacol Sci 2011;15(8):943-9. 9. Martin RL, et al. Foot Ankle Int 2005;26(11):968-83. 10. Valdecanas B, et al. Phil J of Surg & Surg Specialties 2014. 11. Wolgin M, et al. Foot Ankle Int 1994;15(3):97-102. 12. Cagnie B, et al. Phys Ther. 2003;83(8):707-12.

determination may also be done, as well as stan-

dardization of the protocol in terms of amount of

gel used.

CONCLUSIONKetoprofen phonophoresis afforded better

relief from inflammatory heel pain as compared

with plain conventional ultrasonic modality.

MEETING HIGHLIGHTS 44

MARCH 2015 CALENDAR 45

M A R C H

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MARCH 2015 EXPERT OPINION 48

Electronic cigarettes could be one of the biggest public health opportunities of our

time, but that depends on who you talk to. They have been shown to be effective in

helping smokers quit and many believe them to be much safer than cigarettes. But the

debate rages on.

E-cigarettes help smokers quit, ban reflex and ‘no harm’ perception must be challenged

SCICOM – MAKING SENSE OF SCIENCE

Electronic cigarettes could be one of the big-

gest public health opportunities of our time,

but that depends on who you talk to. They have

been shown to be effective in helping smokers

quit and many believe them to be much safer

than cigarettes. But the debate rages on. At the

2015 American Association for the Advance-

ment of Science (AAAS) Annual Meeting held

recently in San Jose, California, US, a panel of

global advocacy, ethical, policy, health, toxicol-

ogy and industry experts from Germany, New

Zealand, South Africa, the UK and US debated:

are electronic cigarettes killing me softly or our

greatest public health opportunity?

E-cigarettes are already used by tens of mil-

lions of smokers around the world. Hundreds of

versions are available online or in specialised

shops. Analysts at Wells Fargo (2013) predict

that sales will outstrip classical cigarettes by

2021. These battery-powered devices work by

delivering aerosol (vapour) containing nicotine

to the user. The apparent medical advantage is

that the vapour produced contains compounds

in the tens to hundreds compared with the 8,600

or more produced in cigarette smoke that cause

life-threatening diseases.

The American Cancer Society estimates that:

• One billion people smoke cigarettes and

the number is increasing.

• Half of cigarette users will die early because

they smoke.

• Six million people die every year because of

tobacco. This figure includes 5 million smokers,

but also about 600,000 non-smokers exposed

to second-hand smoke.

• It is expected that, without action, 8 mil-

lion people will die annually of tobacco-relat-

MARCH 2015 EXPERT OPINION 49

ed causes, by 2030. Over 80 percent of these

deaths will be in low- and middle-income coun-

tries.

• Non-communicable diseases (NCDs) kill

35 million people annually, 80 percent of which

are in low-and middle-income countries. Tobac-

co is responsible for one out of six NCD deaths.

The most recent study undertaken by an in-

dependent authority, The Cochrane Collabora-

tion, and published in December 2014 suggests

that e-cigarettes have a significant role to play

in helping smokers reduce or quit. [Cochrane

Database of Systematic Reviews 2014, Issue 12.

Art. No.: CD010216. DOI: 10.1002/14651858.

CD010216.pub2] This independent network in-

cludes researchers, health professionals and

consumers of healthcare, carers, advocates and

people interested in health from 120 countries.

It also backs third-party research meeting the

high standards it sets. In this Cochrane Review,

two randomised trials were conducted with a to-

tal of 662 current smokers. Admittedly, the num-

ber of studies included was quite small, so the

evidence is not yet strong. However, it did find

that about 9 percent of smokers who had used

electronic cigarettes were able to stop smok-

ing for up to 1 year. This compares with around

4 percent of smokers who used nicotine-free

placebo electronic cigarettes. Among smokers

who had not quit, researchers found that 36 per-

cent of electronic cigarette users reduced their

consumption of tobacco cigarettes by half. This

compared with 28 percent of users who were

given placebos.

Speaker and chief executive of Action on

Smoking & Health UK (ASH) set up by the Royal

College of Physicians, Deborah Arnott, spoke in

favour: “Cochrane reviews are world renowned

for their systematic analysis of the evidence and

our findings at population level are consistent

with their conclusions that electronic cigarettes

have the potential to help smokers quit. Re-

search by ASH over the last 5 years has now

been supplemented by official UK government

statistics to show that almost no one who is not

a smoker is regularly using e-cigarettes. Neither

is there evidence thus far from the UK that the

growth in e-cigarette use is leading to an in-

crease in smoking, particularly among young

people, in fact smoking rates continue to fall.

Continued surveillance is clearly needed, as is

a considered and objective approach from pol-

icy-makers who have very mixed views on what

to do about regulation which is all too often in-

formed by prejudice rather than the evidence.

There is a danger that the precautionary prin-

ciple is being used to deny smokers access to

products which can save their lives. Over 1,000

people will die worldwide from tobacco during

this 90 minute session alone. E-cigarettes have

the potential to dramatically reduce this deadly

toll.”

Speaker and deputy director of the US Na-

tional Institute on Drug Abuse (NIDA), Dr. Wil-

son Compton advocated the middle ground:

“Electronic nicotine delivery systems have both

promise and concern. Let’s remember that

cigarette smoking causes one in five deaths in

the US every year. Every approach to reducing

cigarette smoking should be considered, and

e-cigarette use by smokers attempting to quit

is promising. Nevertheless, advances in brain

MARCH 2015 EXPERT OPINION 50

and gene research are showing that adolescent

exposure needs closer attention. Nicotine is ad-

dictive and addiction is a developmental disor-

der with an abuse trajectory that predominantly

starts in one’s youth. And addiction has its dark

sides. The NIDA-funded Monitoring the Future

(MTF) survey shows that daily cigarette smok-

ing by teens has decreased almost 50 percent

over the past 5 years. Yet, measuring e-cigarette

usage for the first time in 2014, MTF found that

over 17 percent of 12th graders had used them

in the past month and many of these e-cigarette

users had no reported prior use of tobacco ciga-

rettes or smokeless tobacco. My plea is for an

appropriate, rational, scientific appraisal of likely

risks and benefits. Above all, we must do more

to dispel any youth perception that e-cigarettes

cause no harm - they do - while encouraging

adults to do everything they can to stop using

tobacco products.”

Discussant and chief science adviser to the

Prime Minister of New Zealand, Sir Peter Gluck-

man commented: “What is clear is that unless

we obtain robust scientific evidence both as

to short and long-term effects, we will remain

confused as to whether e-cigarettes can be a

positive or negative contribution to public health

and whether their use can be regulated in such

a way as to promote positive rather than nega-

tive outcomes. We need to keep gathering evi-

dence while being prudent from normative ar-

guments as to what to do with this technology.

The realpolitik of policy formation in emotionally

charged areas where there is strong advocacy

for different positions from differing perspectives

and interests is complex. There are some inher-

ently very difficult trade-offs in the debate from

what we currently know. What would be unfortu-

nate is policy based on unscientific positioning

as a result of strong advocacy and selective use

of evidence and a failure to continue research.

This can only lead to ongoing confusion in poli-

cy formation and regulation”.

Speaker and chief medical officer and di-

rector of compliance at Nicovations Ltd, a sub-

sidiary of British American Tobacco, Dr. Kevin

Bridgman added: “There is growing consensus

among public health professionals that e-ciga-

rettes are significantly less risky than conven-

tional cigarettes. However, we believe that, in

order to realise their full potential, e-cigarettes

should be regulated to ensure appropriate qual-

ity and safety standards, whilst also allowing

sufficiently wide retail availability, appropriate

lifestyle positioning and flexibility for the rapid

introduction of product innovation. This would

provide greater confidence without stifling inno-

vation, while enabling these products to com-

pete effectively with cigarettes.”

Discussant and chair of evidence-based toxi-

cology at Johns Hopkins University, Dr. Thomas

Hartung, felt the whole question of e-cigarettes

comes down to new testing standards: “This is

a tremendous public health opportunity, which

we can easily block by applying traditional tox-

icity testing. If you insist on this, you are es-

sentially killing off the sector. Flavours added to

some e-cigarette brands such as pop-corn or

bubble-gum or even gin & tonic are a big issue,

and one wonders why they are there. What is

safe in food is not safe if inhaled. We need data

fast, but we must re-think how to go about it, as

MARCH 2015 EXPERT OPINION 51

traditional toxicology is not fit for this purpose.

To do so, we must find new ways to combine

the knowledge and vested interests of an in-

dustry which is no longer old-school and old-

science tobacco, but highly modern and on a

par with pharma, with the opportunities of new

approaches coming from academia and regu-

latory science. To get there, we have to resist

the reflex of discrediting each-others respective

scientists. Time will tell if we are able to put the

smoker’s health first.”

Panel moderator and president of the Eu-

ropean Group on Ethics in Science and New

Technologies (EGE), reporting to European

Commission President, Jean-Claude Juncker

and to the European Parliament, Professor

Julian Kinderlerer, summed up by advocating

for great understanding and compassion for

the addicted person: “Society both professes

intolerance for the use of ‘drugs’ and provides

the social settings to enable and make legiti-

mate their use. We talk of the rights and re-

sponsibilities of citizens and of how important

the individual is in society, but the inconsisten-

cies in treatment and punishments for various

lifestyle choices are manifest. I wonder are we

really individuals anymore. Autonomy arises

from the concept of dignity as the capacity of

a rational individual to make informed, unco-

erced decisions. As science walks a danger-

ous line between persuasion and informing,

we must be mindful of society stepping in and

requiring individuals to accept norms regard-

less of their own beliefs. In the case of ciga-

rettes and e-cigarettes, history will judge us

harshly as to how we answer this billion per-

son question. It may also look back in anger at

policy-making amounting to institutionalised

manslaughter.”

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S E N I O R E D I T O R

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