P. 1
Medical_Tribune_November_2012_PH

Medical_Tribune_November_2012_PH

|Views: 42|Likes:
digital edition
digital edition

More info:

Published by: AsmphLibrary Ortigas on Nov 28, 2012
Copyright:Attribution Non-commercial

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as PDF, TXT or read online from Scribd
See more
See less

09/24/2013

pdf

text

original

November 2012

Step-off approach to LABA asthma therapy under scrutiny

FORUM Vaccination the key to global health

PHILIPPINE FOCUS PhilHealth signs MOA with pharma

IN PRACTICE Managing HFMD in primary care

AFTER HOURS Crater culture

2

November 2012

Step-off approach to LABA asthma therapy under scrutiny
Elvira Manzano

T

he approach of discontinuing long-acting β2-agonist (LABA) therapy (‘stepoff’ therapy) in patients who achieve control of their symptoms on a combination of LABA and inhaled corticosteroids (ICS) may lead to exacerbation of symptoms and reduce quality of life, according to new research. A meta-analysis of five randomized controlled trials comparing step-off therapy with continued use of LABA and inhaled ICS medications found that the LABA step-off approach was linked to a rise in asthma-related impairment. Compared with patients who continued combination therapy, those who stopped treatment had fewer symptom-free days (608 vs. 622) and lower scores on questionnaires assessing quality of life and overall asthma control. They also required an average of 0.71 (95% CI 0.29 to 1.14) more puffs per day of a rescue bronchodilator and had a non-significant increase in use of oral corticosteroids (RR 1.68, 95% CI 0.84–3.38). There were no deaths and too few exacerbations in the studies to evaluate safety outcomes. [Arch Intern Med 2012; DOI:10.1001/archinternmed.2012.3250] The findings contradict the US Food and Drug Administration’s (FDA) ‘black box’ warning that LABAs, when given with ICS, should be discontinued as soon as asthma control is achieved. “In contrast to FDA recommendations, our analysis supports the continued use of LABAs to maintain asthma control,” said study author Dr. Jan L. Brozek from the department

of clinical epidemiology and biostatistics and medicine, McMaster University, Hamilton, Ontario, Canada. Manufacturers of LABAs are conducting further large-scale safety studies of their products, however the results of these will not be available for 5 years. “In the interim, the consistent trends that we identified for many asthma impairment factors, some of which were statistically significant, favor the continued use of LABAs,” said Brozek. Brozek and his fellow investigators cautioned that the studies were of short duration and had high withdrawal rates. Nevertheless, “our findings likely represent the current best evidence about stepping off LABA therapy in patients with asthma.” While there is consensus that LABAs have no role in asthma monotherapy, the findings help shift the burden of proof in the debate over stepped-down withdrawal of LABAs, wrote Dr. Chee M. Chan and Dr. Andrew F. Shorr, from the division of pulmonary and critical care medicine at Washington Hospital Center, Washington D.C., US, in an accompanying commentary. Moreover, they called on the FDA to reconsider the ‘black box’ warning for these agents based on the findings. “We hope that this meta-analysis helps to lift some of the black clouds in the debate surrounding LABAs,” they said. “Similarly, physicians must now reevaluate the contents of the black box for LABAs, particularly in individuals whose asthma is well-controlled with combination LABA and ICS therapy.”

3

November 2012

Do celebrities help public health campaigns?
Alexandra Kirsten

C

elebrities can help to promote public health and are effective in doing so, says a public health expert in Australia. While celebrities are not always health experts, unlike many health experts, they “often speak personally and bring compelling authenticity to public discourse,” wrote Dr. Simon Chapman, professor of public health at the University of Sydney, Australia, in a recent editorial published in the British Medical Journal. [BMJ 2012;345 DOI: http://dx.doi. org/10.1136/bmj.e6364] Critics of celebrities in health campaigns point to examples which have gone “badly wrong.” They focus on celebrity endorsement of “flaky complementary medicine and quack diets” or incidents where celebrities have veered away from the message. On the contrary, Chapman suggests there are many examples of celebrity engagement that have amplified news coverage about important neglected problems or celebrity involvement in campaigns to promote evidence-based health policy reform. Talking about the case of Australian cricketer Shane Warne, who accepted a six-figure sum to use nicotine replacement therapy to quit smoking, Chapman said “we should not expect perfect outcomes after celebrity engagement and need to be realistic about the need to sustaining public campaigns beyond their first burst.” When photographs appeared of the sportsman smoking again, many experts “failed to exploit” the important message about the risks of relapsing, said Chapman, “instead climbing on a cynical populist bandwagon about his alleged motives.” He also mentioned Australian singer Ky-

lie Minogue’s breast cancer, which “led to an increase in unscreened women in the target age range having mammography, but also to an increase in young women at very low risk seeking mammograms and thus being exposed to unnecessary radiation and falsepositive investigations.” The ambivalence about this effect reflects the debate about the wisdom of breast cancer screening, he said, “but it should not blind us to the potential value of celebrity engagement in important causes.” In response to Chapman’s comments, Dr. Geof Rayner, former chair of the UK Public Health Association and Honorary Research Fellow at City University London, England, said he remains concerned about the influences of celebrities who dabble in the public health arena. While celebrities might help to boost campaigns in the short term, Rayner said they “must tread a cautious path of support because of the risk that the celebrity becomes the story, not the campaign.” [BMJ 2012;345 DOI: http:// dx.doi.org/10.1136/bmj.e6362] Certainly celebrities help shift products, but according to Rayner this “has become mainstream marketing strategy” across society, even in politics. Rather than relying on media stunts, modern health campaigners “need to go on the offensive against junk food, alcohol, gambling, and other often celebrity linked, commercial propaganda.” Rayner postulated new measures to promote public health, for example campaign groups that “bring together the lobbying power of thousands of ordinary people through the internet.” “Some celebrities might help, but let’s not look for saviours, buoyed by the happy thought that the work is done when a celebrity is involved. That’s a lie too”, Rayner concluded.

4

November 2012

Forum

Vaccination the key to global health
Excerpted from a lecture by Edith L. Maes (Ph.D.), senior research fellow, Maastricht School of Management, the Netherlands, at a media briefing in Kuala Lumpur, Malaysia.

I

t has been shown by historical studies that there is a relationship between health and wealth, and that it really pays for governments to invest in health. Because of the dual relationship, there is a double dividend, especially in low- and middle-income countries. The reason is that healthy populations lead to economic growth. When people remain healthy, they also develop better physical and cognitive capabilities, so that in adulthood they become more energetic and active workers, which leads to higher incomes for their families, higher productivity and greater output, which is measured as gross domestic product (GDP) for the government. It is beneficial investing in health preventative measures that do not cost much or preventative measures which need an investment, but have a payoff in the short- and long-term. It is important at the individual level, family or household level, and the government level. Firstly, it is important at the individual level, especially to children, since they are vulnerable and contract diseases very easily because their immune system is not working well. If children are healthy, it’s better for the families because they will be able to develop their cognitive and physical abilities so parents will be able to continue working and generating an income. But if the child is sick often, the family incurs huge medical costs. In many countries, because of large out-ofpocket expenses, it also costs households a lot of savings, which indirectly has a long-term

effect. At government level, it is important because investing in health means actually investing in the workforce. So a healthy workforce is good for the country because it increases productivity and, as a consequence, its income. One measure to express health is life expectancy. Health can be defined in many ways, so epidemiologists and economists as well have taken one common measure, which is life expectancy, to express the benefits that accrue in a healthy population. Life expectancy is a measure at the population level – it’s an average among all individuals that survive in society. So, if large numbers of children die prematurely, the life expectancy will go down. In the early 1900s, most countries had low levels of income and life expectancy was 55 to 60 years. Gradually, especially in western countries, health improved because of better sanitation, potable water and preventive measures like vaccines, and that increased the life expectancy in developed countries to 65 to 75. In 2010, when we cluster the countries, the high-income countries moved up to 70 to 82 years of age and their income also increased from US$14,000 to US$47,000, so their income increased accordingly to the increase in life expectancy. So that is how economies expressed the benefits of investing in health and tried to establish the relationship. Why is it that health in such nations and communities in general can improve? It is because the government

5

November 2012

Forum
The first few vaccines were developed for diphtheria, tetanus and polio – those vaccines were based on simple technology and can still protect against those killer diseases. The latest vaccines are based on complex technologies against rotavirus, pneumococcal diseases and human papillomavirus. These vaccines have taken a long time to develop, and are complex and more expensive than those developed in the 1950s and 1960s. The Global Alliance for Vaccines and Immunisation (GAVI) was founded in 2000 to fund vaccines in very poor countries that cannot afford any immunization programs or expand it with newer vaccines, and are also lacking a proper health infrastructure to provide vaccines to children in rural areas. The GAVI Alliance is a public-private partnership built on international solidarity and it devised a very innovative way of financing through donor fronts from a number of countries and foundations including the Bill & Melinda Gates Foundation. There are a number of Western countries that have been pledging millions of dollars every year to vaccination, which can be used in the low-income countries with incomes below US$1,500 per person per year to give them an incentive to start developing their programs. Through the GAVI Alliance, rigorous government policies, and strengthening of vaccination programs at the country level, over 5.5 million lives have been saved since 2000. [GAVI Alliance Progress Report 2011. www. gavialliance.org/results/gavi-progress-reports/ Accessed on 24 September] The assessment of costs and effectiveness is becoming an increasingly important factor for policymakers faced with decisions about adding a new vaccine to national immunization programs.

decides to take measures, which can be very simple ie, educational programs to improve sanitation at home and building infrastructure to provide potable water for everyone. One of the measures that governments have been investing in is immunization for its short- and long-term benefits. In all the studies that have been done, the global community has recognized that vaccination is one of the world’s most important and cost-effective health interventions, with positive socioeconomic effects on society. [World Economics 2005;6:15-39] Key stakeholder benefits of vaccination include reduction in morbidity and mortality among individuals, which result in healthy families, a more productive workforce and herd immunity in society. It is in the interest of governments to invest in vaccination programs that are successful ie, that reach a coverage level of above 85 percent. When that level of protection is reached in the community, weaker and vulnerable people will also benefit from the decreased pool of pathogens. In the past 30 years, there has been a rapid increase in the number of vaccines. We are now at a point where we can prevent approximately 20 diseases through vaccination programs, although sometimes it is only useful for certain target groups like travelers or healthcare workers. Looking at the evolution of vaccines – the very first vaccine, for smallpox, was actually experimentally tested in the 1800s. The person who tested the vaccine in farmers found that those who had been primed with pieces of the smallpox virus did not develop smallpox later in life. Gradually, the principle of priming the immune system started being recognized as being a very effective prevention method for certain diseases.

6

November 2012

Forum
We have seen many success stories in governments adopting the hepatitis B, pneumococcal and Haemophilus influenzae type B childhood vaccines. Investing in vaccination gives a high return in the short- and long-term for both individuals and society as a whole, and is based on the principle that health is a human right, so why would we deny it to ourselves or to our children?

To be able to compare with other studies and to compare between diseases, the WHO has come up with a metrics called DALY (disability-adjusted life years), which is a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability. This common measure allows governments to compare across diseases and technologies.

7

November 2012

Philippine Focus

CONFERENCE COVERAGE
21st Perinatal Association of the Philippines Annual Convention; September 30-October 1, 2012; Crowne Plaza, Ortigas

Newborn screening to further expand coverage
Dr. James Salisi

N

years. “The next ten years is about expanded newborn screening. It is anything that’s beyond congenital hyperthyroidism and PKU (phenylketonuria). It’s talking about more metabolic disorders, hemoglibinopathies, lyzosomal diseases, very rare diseases that are being screened by developed countries,” said Dr. Carmencita Padilla, chair of the Department of Pediatrics of the Philippine General Hospital. The current system screens five potentially life-threatening disorders: congenital hypothyroidism, congenital adrenal hyperplasia, PKU, galactosemia, and glucose-6-phosphate dehydrogynase deficiency. The new testing technology will not alter the way samples are collected now, which is to get 3 samples in one newborn screening filter paper. The difference lies in the number of metabolites and diseases that can be analyzed by the machine. Whereas the classic approach analyzes one metabolite and one disease, the new approach will be able to analyze more metabolites and more diseases including hemoglobinopathies and greater than 20 amino acid disorders.

ewborn screening in the Philippines is set to expand its coverage from the basic five to 28 disorders in 10

“We have a lot of hemoglobinopathies, a lot of organic acid disorders, a lot of fatty acid disorders and, to my surprise, cases of cystic fibrosis,” Padilla said, citing a study in California in a presentation at the Department of Health. She highlighted the need to increase the number of diseases screened at birth in order to save more lives.

Newborn screening is a public health program in all parts of the world
“Newborn screening is a public health program in all parts of the world,” said Dr. Padilla. She explained that it is a universally

‘‘

8

November 2012

Philippine Focus
will be established at the National Institutes of Health in UP Manila while endocrinology confirmatory laboratories will be set up in government and private laboratories. Regional long-term follow-up clinics will be set up to give free services to confirmed cases of disorders screened by the program. The Centers for Health Development of the Department of Health will identify the host institutions of these clinics which should have at least a hematologist and a neonatologist. A grant will be given to the host institution for personal services and maintenance and operations expenses. “The program will have a net benefit of 600 million pesos a year if all babies are screened and all positive cases are treated. It is a benefit for the family because they take care of the [patients],” Padilla said while citing a costbenefit study that she did for newborn screening in the Philippines.

accepted public health program aimed at the early identification of the infants who are affected by certain genetic, metabolic or infectious conditions. The expanded program started its preparatory phase in July this year and the pilot study will be implemented in December to February 2013. The national implementation will start in March 2013 and will include endocrinologic disorders, amino acid, fatty acid and organic acid disorders, and hemoglobinopathies. In preparation for the expansion, regional and provincial medical center follow-up clinics will be established, laboratory equipment will be upgraded and staff will be trained. Workshops for long-term follow-up of metabolic and hemoglobinopathy cases were done in February and August, respectively, this year. Discussion with PhilHealth to increase funding for expanded screening is ongoing. A biochemical genetics reference laboratory

Maternal nutrition may dictate metabolic syndrome in children
Gabriel Angelo Sembrano

N

eonates are at risk for metabolic syndrome if he or she was conceived in an at-risk environment but the risk could be modified if recognized and addressed preconceptually,” stated Dr. Lorna Abad, head of the Pediatric Endocrinology section of the Philippine Children’s Medical Center. “It had been found that the factors present in the fetal-neonatal period that correlated to later obesity risk include maternal undernutrition, which is caused by smoking and al-

coholic intake. There is vascular insufficiency—even for those living in high-altitudes,” Abad added. According to Abad, it is important to take note on these factors since these are potentially modifiable. Success in the modification of these behaviors could benefit both the mothers and the infants. As an evidence of maternal deprivation posing a risk for developing metabolic syndrome among neonates, Abad cited the Dutch winter famine experience in the Netherlands during 1944 to 1945. The study explained that if the insult is close to the

9

November 2012

Philippine Focus
in contrast, iron supplementation during pregnancy leads to a higher birth weight [The Journal of Physiology, 561;195-203]. She also highlighted that the timing of iron supplementation is critical in reversing the effects of maternal anemia on the developing fetus. On the other hand, Abad said that maternal overnutrition could also lead to the development of metabolic syndrome among infants. She cited a study by Whitaker in 2004 which showed that children who were born to mothers with BMI falling under the obese category during the first trimester are twice as likely to develop obesity by two years of age. “Most of the risk factors for metabolic syndrome are pre-natal in nature so we should make sure that obesity is prevented in pregnancy,” Abad stressed. She added that it is ideal for obese or overweight women to lose weight prior to conception. If the woman is already pregnant and at the same time overweight, she should at least receive behavior modification counseling to make sure that she will not gain weight beyond what is recommended.

latter part of the gestation, there is a greater risk for infants to develop glucose intolerance. “The offsprings of mothers who were pregnant at this time had impaired glucose tolerance since there was no food supply due to the war,” Abad said. According to Abad, there have been some observable patterns that suggest fetal injury at specific periods during gestation. A body mass index that is less than the normal level may reflect malnutrition at a certain period during the third trimester of pregnancy. She added that if the head circumference is below the normal measurement which is 33 cm to 35 cm, it reflects sluggish growth throughout gestation and further suggests that the injury took place at early stage in the fetal development. Abad pointed out that a typical example that causes fetal injury during gestation is maternal micronutrient deficiency. She cited a study by Gambling et al which showed that neonatal body weight decreases with the exacerbation of maternal iron deficiency; and

10

November 2012

Philippine Focus

Conference Calender NOVEMBER
Philippine Obstetrics and Gynecology 2012 Annual Convention and 66th Anniversary Celebration November 6-9, 2012 Venue: Philippine International Convention Center and Sofitel Philippine Plaza Hotel Info: Philippine Obstetrics and Gynecology Society Phone: +632 921 7557; 921 9089; 435 2384, 4352385 Email: pogs@pldtdsl.net Website: www.pogsinc.org 34th Philippine Neurological Association Annual Convention November 7-10, 2012 Venue: Capt. John Hay Convention Center, Baguio City Info: Philippine Neurological Association Phone: +632 723 2102 Email: philneuro@gmail.com Website: www.pna.org.ph Philippine Society for Parenteral and Enteral Nutrition 8th Annual Convention November 13-14, 2012 Venue: Manila Diamond Hotel Info: Philippine Society for Parenteral and Enteral Nutrition Phone: +632 723 0401 Local 5714 Fax: +632 725 6868 Email: philspen_sec@yahoo.com Website: www.philspenonline.com.ph 13th Philippine National Immunization Conference November 14-15, 2012 Venue: Baguio Country Club Info: Philippine Foundation for Vaccination Phone: +632 254 5205 Email: pfvinc@yahoo.com Website: www.philvaccine.org 29th Annual Convention of Diabetes Philippines November 14-16, 2012 Venue: EDSA Shangri-La Hotel Info: Diabetes Philippines Phone: +632 534 9559 Email: diabetesphilippines@pldtdsl.net Website: www.diabetesphil.org/ 63rd Philippine Orthopaedic Association Convention November 14-17, 2012 Venue: Crowne Plaza, Quezon City Info: Philippine Orthopaedic Association Tel. No.: +632 667 3926; 667 3946 Email Address: mikee@philortho.org; celia@philortho. org; weng@philortho.org Website: www.philortho.org Philippine Academy of Ophthalmology Annual Meeting 2012 November 29-December 2, 2012 Venue: Medical Plaza Makati Condominium, Makati City Info: Philippine Academy of Ophthalmology Tel. No.: +632 813 5324; 813 5318 Email: secretariat_pao@globelines.com.ph Website: www.pao.org.ph

11

November 2012

Philippine Focus

CONFERENCE COVERAGE
21st Perinatal Association of the Philippines Annual Convention; September 30-October 1, 2012; Crowne Plaza, Ortigas

Music therapy eases maternal anxiety during breastfeeding
Dr. Yves Saint James Aquino

M

usic therapy may provide relaxation and improve new mothers’ perception of breastfeeding, according to a study by Dr. Klarisa MarianoEnrique done in St. Luke’s Medical center, Quezon City. Included in the study were women who were admitted at St. Luke’s Medical Center and who had just delivered either vaginally or abdominally for the first time. Mothers with clinical problems such as encephalopathy, oro-facial anomalies, cardiac problems or other congenital anomalies, or those with babies admitted at the neonatal ICU were excluded from the study. A total of 78 mothers were included and were randomly divided into experimental and control groups. Experimental subjects received music therapy prior to breastfeeding, with minimum duration of 10 minutes of patient’s choice of music. Both experimental and control subjects were observed by the research assistant as soon as the mother initiated breastfeeding. The survey immediately followed the breastfeeding attempts using a 7-point Likert scale, with 7 being the most positive (relaxed).

Results showed that the control group had higher score compared to the music group. However, comparing the pre-test and the post-test of the experimental group, results showed that there is significant improvement in mothers who were exposed to music therapy. Mean score of the experimental group were higher in post-test compared to pretest when asked if they are relaxed (6.36 vs 4.74; p<0.001), and when asked if they are anxious about breastfeeding in the future (6.69 vs 4.74; p<0.001). “The outcome of the study reveals that music therapy offers a therapeutic intervention that reduces the anxiety of first time mothers who are breastfeeding in the immediate postpartum period and increases their overall sense of well-being,” said Mariano-Enrique. Music therapy has been previously shown to promote positive effects in several areas of study, such as mental health, special education, rehabilitation and social development, said Mariano-Enrique. The researcher recommended further studies that can improve the technique in administration of music, that can assess the use of individual music preference versus a standardized music and can study the cumulative effect of music.

12

November 2012

Philippine Focus

CONFERENCE COVERAGE
21st Perinatal Association of the Philippines Annual Convention; September 30-October 1, 2012; Crowne Plaza, Ortigas

Kangaroo mother care promotes neonatal growth
Dr. Nicolo Cabrera

K

angaroo mother care (KMC) was shown to cost-effectively promote growth, euglycemia and euthermia in infants born weighing less than 2,000 g in a prospective randomized controlled trial done at a Level III neonatal intensive care unit (NICU) of a tertiary government hospital in the Philippines. “Neonates, regardless of parents’ financial capability, should receive the best possible care,” opined Dr. Remelie Ballesteros of Mariano Marcos Memorial Hospital & Medical Center in Batac, Ilocos Norte. She revealed that 20 million infants were born with low birth weight annually, comprising 15.5 percent of all births. She said that in the Philippines, 16.65 percent of the population were born low birthweight, emphasizing the burden of illness in our country. A prior meta-analysis had pooled three RCTs to show that KMC reduced causespecific mortality compared to standard care as well as five RCTs to show reduced severe morbidity. [Int J Epidiol 2010;39: i144-i154] Among 1,821 live newborns screened in the study, 82 were born below 2,000 g. Twentyfive infants were randomized to receive KMC, another 25 to receive conventional method of care (CMC). Thirty-two were excluded. The

KMC group underwent skin-to-skin contact for two-hour periods several times a day, while the CMC group were placed in cradles under hot lamps using 5-watt incandescent bulbs. Compared to the CMC group, the KMC group had higher daily in-hospital weight gain (7.5 versus 2.6 kg, p<0.0001); shorter hospital stays due to the earlier achievement of ideal weight (9.3 versus 22.0 days, p>0.0001) and higher post-discharge weekly weight gain (184.8 versus 128.0 kg, p<0.0001). Average weekly length gain was 51.7 percent better in the KMC group (p<0.0001) and average weekly head circumference gain was 60.6 percent better as well (p<0.0001). The KMC group had higher daily RBS averages (66.0 versus 56.8 mg/dL, p<0.01) and achieved ideal RBS in fewer days than the conventional care group (3.6 versus 11.6 days, p<0.0001). The KMC group achieved ideal temperature in fewer days than the conventional care group (approximately 4.0 versus 12.0 days). Eight infants receiving CMC suffered morbidity or mortality (eg, from infection and nosocomial sepsis) whereas none receiving KMC did. “Evidence suggests that KMC is a safe and effective alternate method to conventional neonatal care,” posited Ballesteros. She computed that infants below 1,500 g

13

November 2012

Philippine Focus
Apart from aspects investigated in Ballesteros’ study, the WHO also includes the following practices under the bundle of KMC: exclusive breastfeeding, continued KMC at home and early discharge.

receiving CMC stayed in the NICU about 21 days and racked health care costs up to Php 52,500.00. However, providing KMC cuts NICU stay down to nine days, saving the family Php 30,000.00.

Intimate partner violence screening neglected in patient care
Dr. Nicolo Cabrera

S

creening patients for intimate partner violence (IPV) is a neglected component of optimal health care, particularly of the pregnant woman and the child she carries, said Dr. Lyra Ruth Clemente-Chua, professor of obstetrics and gynecology at the Manila Central University-Filemon D. Tanchoco Medical Foundation. “During conventions like this, we talk about the biomedical aspects of the care of the woman and the child, pero … ilan sa atin ang aware that this [IPV screening] is an important part also of the care?” ClementeChua asked. In the Philippines, 4 percent of women who have ever been pregnant report experiencing physical violence during their pregnancy with an incidence that increases slightly with the number of living children the woman has. The incidence of such violence declines slightly with increasing age and educational level and steadily with increasing wealth quintile. Clemente-Chua presented several studies demonstrating the multiple effects of IPV on the mother and the child. A woman who suffers abuse is at increased risk for the following health problems: blunt traumatic injury

(resulting in abruptio placenta or uterine rupture), elective pregnancy termination, anemia, sexually transmitted infection, urinary tract infection, preterm labor, chorioamnionitis, substance abuse, depression, preeclampsia and poor placentation. These women tend to experience a prolonged second stage of labor, particularly after sexual abuse. They are also more likely to deliver low birth weight infants due to preterm delivery, prolonged premature rupture of membranes and maternal low weight gain. IPV also subjects the child to stress in utero. Clemente-Chua presented research demonstrating the effects of stress during fetal life that manifest further along the child’s development such as self-regulation and temperament difficulties and even attention deficit hyperactivity disorder. “When we see women come in with these injuries, do we ask them? Or do we just close our eyes?” Clemente-Chua posed to the audience. She shared that the US Centers for Disease Control and Prevention (CDC) cites four barriers to screening: time constraints, discomfort with the topic, fear of offending patient or partner, and perceived powerlessness to change the problem. She advised that clinicians should

14

November 2012

Philippine Focus
tempt to speak with the woman in private by examining her in another room and should ask about IPV several times.

suspect IPV when they see a meek woman accompanied by a partner who answers all the clinician’s questions. The clinician may at-

Clemente-Chua offered the CDC’s RADAR mnemonic to guide screening for possible victims of intimate partner violence. 1. Routinely screen every patient at first prenatal visit; at least once per trimester; at postpartum checkup; and at routine obstetricgynecological and preconception visits. 2. Ask directly, kindly and nonjudgmentally. 3. Document your findings. 4. Assess the patient’s safety. 5. Review options and provide referrals.

Interpregnancy interval affects adverse maternal outcomes
Gabriel Angelo Sembrano

T

he number of years of interval from one pregnancy to the other may contribute to the development of adverse maternal outcomes, according to a retrospective review by Dr. Sheila Marie Alvarado of Delos Santos Medical Center in Quezon City. “This study showed that there were significantly more patients who developed either hypertensive complications of pregnancy or diabetes mellitus for interpregnancy interval of more than 5 years and preterm delivery and postpartum hemorrhage than those with interpregnancy interval of less than 2 years,” Alvarado explained. “A total of 1,799 singleton pregnancies composed of pregnant women gravida 2 and above, with no medical or obstetrical complications or comorbidities during their first or previous pregnancies, and whose preced-

ing births were term live births delivered vaginally and without complications were included in this study,” Alavarado said, explicating the inclusion criteria. In the analysis of outcomes, Alvarado included the occurrences of hypertensive complications of pregnancy, diabetes mellitus, preterm delivery and postpartum hemorrhage. Furthermore, a receiver operating characteristic curve had to be shown the cut-offs for interpregnancy interval in years. Adverse maternal outcomes were then examined using odds ratio at 95 percent confidence intervals following a logistic regression analysis to account for confounding variables. It was found out that among those who had an interpregnancy interval of more than 5 years, around 68.1 percent (n=207) had hypertension and 43.8 percent (n=133) had diabetes mellitus as opposed to those who had

15

November 2012

Philippine Focus
preterm delivery and 26.5 percent (n=103) had postpartum hemorrhage compared to those who had an interval of more than 2 years where only 0.6 percent (n=9) had preterm delivery and 1.2 percent (n=17) had postpartum hemorrhage (p<0.001). This would suggest that women who had an interpregnancy interval of 2 years and below were almost 77 times more likely to encounter a preterm delivery and almost 22 times more likely to experience postpartum hemorrhage on their succeeding pregnancies than those women who had an interpregnancy of more than 2 years.

an interval of 5 years and below in which only 9.5 percent (n=142) had hypertension and 6 percent (n=90) had diabetes mellitus (p <0.001). According to Alvarado, based on the result of the odds ratio, those pregnant women who had an interpregnancy interval of more than 5 years are 7 times more likely to develop hypertension and diabetes mellitus on their succeeding pregnancies than those who had an interval of 5 years and below. On the other hand, the study also showed that among those women who had intervals of 2 years and below, 49.1 percent (n=191) had

The Complete Solution
Innovations in workflow tools for smarter prescribing. www.mims.com Log on today!
CLINICAL PAPERS PRESCRIPTION INFORMATION PILL IDENTIFIER

PATIENT EDUCATION

DRUG INTERACTION CHECKER MEDICAL NEWS

100%

pure knowledge

MEDICAL EVENTS PUBMED

CME

16

November 2012

Philippine Focus

TREATMENT FOCUS: Cervical Insufficiency

Redefining diagnostics and treatments for cervical insufficiency
Dr. James Salisi

A

35-year-old woman on her third pregnancy presented with a y-shaped, 2-cm cervix length on ultrasound. Her first pregnancy terminated in a missed abortion and had dilatation and curettage at 12 weeks age of gestation. Her second pregnancy was delivered preterm at 29 weeks; but despite this, she had an unremarkable prenatal course. Does this patient have an incompetent cervix? What would be the best management for her? “Cervical incompetence has been entered into medical literature since the 1600s but only during the last 40 years that it gained significance or focus because of problems we encounter with this condition,” said Dr. Maria Luisa Acu from Saint Luke’s Medical Center in Quezon City during the 21st Perinatal Association of the Philippines Annual Convention held last September 30 to October 1, 2012 at Crowne Plaza Hotel, Ortigas. Definitions and diagnostics According to Acu, cervical incompetence is defined by the failure of the cervix to retain the conceptus during pregnancy due to a structural and or functional weakness. “It is the premature ripening of the cervix. If you review the current literature the term incompetent cervix has been replaced by the term cervical insufficiency

‘‘

The most important cause of cervical insufficiency is when we do overzealous dilatation and curettage

because some leading organizations think that ‘incompetent’ is a pejorative term,” Acu explained. Causes of cervical insufficiency may be structural (congenital or acquired) or functional with no obvious pathology. Congenital causes may include collagen abnormalities, uterine anomalies and biologic variations. Acquired risk factors include obstetric trauma, mechanical dilation and treatment of cervical intraepithelial neoplasm. Infection such as bacterial vaginosis has also been linked to a weakened cervix but

17

November 2012

Philippine Focus
that we use transvaginal cervical length measurement. We can use this definition even in primigravidas or multigravidas without prior pregnancy losses,” said Acu. A cervix less than 25 mm in length and/ or advanced cervical changes before 24 weeks in women with either one or more pregnancy losses or preterm births at 14 to 34 weeks, or other significant cervical risk factors. Acu cited a study that showed a strong reproducible inverse correlation between cervix length and preterm delivery. There is a 6-fold increased risk of delivery prior to 35 weeks if the cervix length is less than 25 mm [NEJM. 1996;334:557-567]. This criterion has a sensitivity of 68 to 100 percent and a specificity of 44 to 79 percent according to the American College of Obstetrics and Gynecology practice bulletin. Recommended treatment strategies Placement of cerclage significantly reduced preterm birth (RR 0.80, 95 percent CI, 0.69-0.95) according to a Cochrane review of 9 trials including 2,898 women. [Cochrane Database Syst Rev 2012] “In whom do we put a cerclage? We can group them into the history-indicated cerclage group. This is done at 12 to 14 weeks,” said Acu. The criteria for this group are the presence of two or more consecutive prior second trimester pregnancy losses or three or more early preterm births (less than 34 weeks), risk factors for cervical insufficiency and other causes of preterm birth have been excluded. Supplementation of 17-alpha-hydroxyprogesterone caproate at 16 to 36 weeks helps the pregnancy reach nearer to term in patients with cerclages.

there is not enough evidence to prove the association between the two. “The most important cause of cervical insufficiency is when we do overzealous dilatation and curettage. Three or more first trimester-induced abortions by dilatation and curettage carry a 12 percent risk of a spontaneous pregnancy loss. While a second trimester induced abortion carries a 14 percent risk,” said Acu. Many patients with cervical insufficiency are asymptomatic. Those with symptoms experience mild manifestations such as pelvic pressure, premenstrual-like cramping or backache, increased vaginal discharge and mild contractions. They usually present for several days or weeks from 14 to 20 weeks age of gestation. A soft, somewhat effaced cervix with minimal dilation presents in a patient with early signs of cervical insufficiency. Valsalva’s rarely reveals membranes in the endocervical canal and there are no or infrequent contractions at irregular intervals. In contrast, late physical examinations will show advanced dilatation at greater than 4 cm and effacement at greater than 80 percent and vaginal spotting. There may be either unprovoked grossly prolapsed or ruptured membranes. The contractions seem to be inadequate to explain advanced dilatation and effacement of the cervix. Rule out cervical insufficiency when there are signs of infection, bleeding from placental causes or multiple gestation that may cause cervical opening, advised Acu. Traditional diagnosis relied on historical factor, resulting in delayed diagnosis until at least two pregnancy losses or births before 28 weeks of gestation. “The preferable definition nowadays is

18

November 2012

Philippine Focus
use of unnecessary antibiotics may lead to the development of resistant strains of bacteria and other morbidity for the patient and her fetus,” said Acu. Patients with very poor history of preterm deliveries can have preconception transabadominal cerclage placement. According to Acu, this procedure is easier, with smaller incision, safer to fetus and can be done laparascopically. The rate of carrying the pregnancy to term with prophylactic transabdominal cerclage approaches 90 percent but when it is performed on an emergent basis the success rate drops to less than 60 percent. “We should inform our patients about complications because these are very

“Just a very few women have a historyindicated cerclage. Majority will be in this group: They have suspected cervical insufficiency but do not meet the criteria for history indicated cerclage. This is where we do our screening by transvaginal scan,” said Acu. Serial measurements of cervical length are done. If the length decreases to less than 25 mm, obstetricians give progesterone and apply cerclage. Screening in suspected cervical insufficiency patients starts at 14 weeks or as early as 12 weeks if with early second trimester losses, recurrent second trimester losses or prior large cold knife conization. If the patient has had preterm birth at 28 to 36 weeks, screening will start at 16 weeks. The

‘‘

Once we put cerclage it can be displaced, that’s why we do serial monitoring
common. Once we put cerclage it can be displaced, that’s why we do serial monitoring. We will see if it’s in the proper position or not. As we do the procedure, we can rupture the membranes and we can induce infection,” warned Acu. Life-threatening complications of uterine rupture and maternal septicemia are extremely rare but have been reported with all types of cerclage. Other interventions include pessary, which supports the cervix and turns it backward towards the sacrum, obstructing the internal os. Lifestyle interventions include cessation of work and exercise, abstinence from coitus, bed rest, and limited activity.

interval between cervical length monitoring inversely varies with the length of cervix at baseline. This is discontinued at 24 weeks because at this time cerclage will not be performed anymore because these preterm changes usually precede overt preterm labor by 3 to 6 weeks. A very short cervix (<5 mm) on transvaginal ultrasound or a dilated cervix with visible membranes less than 24 weeks indicate cerclage in some patients. But prior to cerclage, the physician must ensure that there is no overt infection, ruptured membranes and significant hemorrhage. “Majority will use antibiotics prophylactically, or during the procedure and tocolytics during and then stop it. Prolonged

19

November 2012

Philippine Focus

PhilHealth signs MOA with pharma companies for discounted medicines
Dr. Yves Saint James Aquino

T

he Philippine Health Insurance Corporation (PhilHealth) recently signed a memorandum of agreement with 11 top pharmaceutical companies to decrease prices of drugs and medicines for certain illnesses under the PhilHealth Z benefit package. The MOA signing was headed by PhilHealth president and CEO Dr. Eduardo Banzon and attended by representatives of the 11 pharmaceutical companies, along with the representatives of the Philippine Chamber of Pharmaceuticals Inc. and the Pharmaceutical and Healthcare Association of the Philippines (PHAP). Included in the group of companies were PHAP members Sanofi-Aventis Philippines, GlaxoSmithKline Philippines, Novartis Healthcare Philippines, Pfizer Philippines and Roche Philippines. Astellas Pharma Philippines, which will soon join PHAP, also signed the agreement. Other non-PHAP members present included Ambica International Trading, DeGa International Pharma Corp., Globo-Asiatico Ent. Inc., Pascual Pharma and Philippine International Trading Corporation Pharma. “We commit to provide quality benefits; likewise, we find ways that these benefits be brought to and felt by PhilHealth members by ensuring sufficient supply of drugs and medicines in government hospitals to guarantee better health outcomes and financial risk protection,” said Banzon. Dubbed ‘One with Pharma Z,’ the partnership aims to address the problem of accessibility, especially for the marginalized sector. The program hopes to lessen the burden of Phil-

Health members afflicted with catastrophic diseases by ensuring hassle-free availment, Banzon added.

‘‘

We commit to provide quality benefits; likewise, we find ways that these benefits be brought to and felt by PhilHealth members

Catastrophic illness according to the Z benefit package includes acute lymphocytic leukemia, breast cancer (stage 0 to IIIa), prostate cancer and kidney transplant. “We offer our medicines, our expertise, and support to PhilHealth as it embarked on this program,” said Mr. Thomas Marcel Go III, representative of the PCPI. Under the agreement, the companies will provide the initial 21 selected government Levels 3 and 4 hospitals located nationwide with drugs and medications at discounted price to be availed by members who have qualified. Included among the contracted hospitals were Jose B. Lingad Memorial Hospital, Dr. J. Paulino Memorial Medical Center, Batangas Regional Hospital, Bicol Medical Center, Bicol Regional and Teaching Hospital, Western Visayas Medical Center, Dona Corazon Locsin Montelibano Memorial Medical Center, Vicente Sotto Memorial Medical Center,

20

November 2012

Philippine Focus
Institute, Philippine Children’s Medical Center, Quirino Memorial Medical Center, Rizal Medical Center, Jose Reyes Memorial Medical Center and Baguio General Hospital.

Northern Mindanao Medical Center, Davao Regional Hospital, Southern Philippines Memorial Medical Center, East Avenue Medical Center, National Kidney and Transplant

www.MIMS.com
Smart Rx. Every Time.

21

November 2012

Philippine Focus

NOTES ON LEADERSHIP

Collaboration to promote maternal and newborn care
fter 22 years, the Perinatology Association of the Philippines (PAP) has gathered diverse members that included pediatricians, obstetricians, midwives and nurses. The association has grown to include as its affiliate society the Philippine Society of Newborn Medicine, along with Philippine Pediatric Society, Philippine Obstetrical and Gynecological Society, Integrated Midwives’ Association of the Philippines and Maternal and Child Nurses Association of the Philippines. “When the founders were conceptualizing the association, they were thinking more of the health providers that were concerned with the mother and the child,” said Dr. Ma. Theresa Hilario-Jimenez, a practicing pediatrician. Lasting from the 28th weeks of pregnancy up to the first 28 days of the neonatal period, perinatology is concerned with the combined care of the mother and the newborn, thus requiring an integrated delivery of health care. “What we wanted is to get all the healthcare providers who are in charge in order for us to help each other in improving the services that we can give the mother and the child. Ayaw namin magconcentrate lang sa doctors. If you will see, about 75 percent of deliveries are done by the midwives; it’s not done in the hospital. “Each and every one has a role to play and each and every one has something to contribute in order to improve the health status of mothers and children,” added Hilario-Jimenez.

A

Dr. Ma. Theresa Hilario-Jimenez Vice President Perinatology Association of the Philippines

To further improve PAP’s service to the community, Hilario-Jimenez emphasized the importance of training and sharing of knowledge amongst the association’s members. “We have to make sure that our nurses and midwives are updated as we help them in the skills that they need and in the knowledge that they need in order to manage efficiently and effectively the patients,” she said. A system of referral is also being promoted, with community practitioners, such as midwives, being taught when and how to refer when the cases are beyond their capacity.

22

November 2012

Philippine Focus
are founded on community partnership. The fact that the association includes members other than doctors is a testament to their mission to promote a collaborative health care delivery. Whether it’s the community nurses, the midwives, the barangay health workers or the lay people, members of the community should be treated as partners. “The first thing we should do is to make them feel that we are not there to alienate them. We are not there as somebody higher than them. We have to be co-equals. Because what we want is to decrease mortality and morbidity and improve health status of all. And if they will feel that our intentions are really for their benefit, and then for the benefit of the children and the mothers, I think we’re not going to have problems. Siyempre, we also have to be sincere,” said HilarioJimenez. “If they’re going to see that you acknowledge their role, they will appreciate it. I think yun yung pinaka-primary goal namin, because we always make it a point to tell them, hindi naman namin kaya yan lahat, kasi kayo yung nasa community, you can handle them,” she added. To hear members of the community asking questions during lectures and lay fora makes all the efforts worthwhile, according to Hilario-Jimenez. “If we hear them telling us that we come back, if we hear them that we want these topics to be discussed, for me that’s one fulfillment,” she said. “Of course it would be more fulfilling for us if we can get the improvement in statistics. Because that’s the definite [standard]. Mas concrete yung result na makikita mo. That’s our mission, that’s our main goal to decrease the morbidity and mortality of mothers and children,” she concluded.

Hilario-Jimenez explained that one of the challenges faced by the society is increasing its coverage to be able to educate more perinatal practitioners. “When we were doing our rounds, we have lectures in different areas. [Participants] still clamor for a lot of things and it means that they feel that they need to learn about these things. For us, it’s good, kung hindi kayo magsasalita kung anong kailangan, how will we know how to help you,” she said. There is also a problem in the number of doctors who are practicing in communities. “Midwives cannot handle it all. Actually, they are only on the first part of spectrum of health care. So, kailangan pa rin mas maraming doctors na nasa [community] to assist the midwives. One, we have to face it, we have very limited number of hospitals. Two, are they equipped? Three, do they have medicines? Same questions na yun, so I think yun ang pinakamalaki namin naging problema,” shared Hilario-Jimenez. To promote the goals of the association, PAP created programs to establish partnership with different communities. The PAP Caravan goes to different society chapters in IloIlo, Cagayan de Oro, Ilocos, Davao, among other areas, to update members on best practices and new developments in the field of perinatology. PAP is also promoting Kangaroo Mother Care, a low-cost method of managing lowbirth-weight and premature infants. PAP adopted KMC sites at the Gat Andres Bonifacio Memorial Medical Center and Bless Tetada Kangaroo Mother Care (KMC) Foundation Inc., to help further educate doctors, midwives and nurses on how to adopt this method. PAP is probably one of the societies that

23

November 2012

Philippine Focus

‘Customer displeasure’ deters self-care of Filipino diabetics
Dr. Nicolo Cabrera

C

ustomer displeasure’ was one of several deterrents to self-care behavior identified in a qualitative study of Filipinos with Type 2 diabetes mellitus (T2DM) completed last year by Mr. Stimson Agustin, Jr. of Centro Escolar University-Manila. Published in the Cebu Normal University Journal of Higher Education, Agustin described self-care as a “self-initiated, intentional and purposeful activity” wherein the patient “chooses the methods of healthy behaviors.” These behaviors entail the use of knowledge about their diabetes to balance their physical, emotional and activity levels as well as manage drug and nutritional intake to optimize glucose control. While he was able to access studies on self-care among Filipinos with diabetes living in the US, he found a dearth of such studies on Southeast Asians still living in their countries of origin, including Filipino diabetics still living in the Philippines. He interviewed six purposively sampled Filipinos with T2DM as well as their primary caregivers and collected self-care diaries accomplished during the three days prior to the interview. Customer displeasure emerged as one of four deterrents or factors that prevented self-care behavior from occurring identified by the study. Long lines and waiting times were cited as sources of dissatisfaction for the patient, potentially straining the doctorpatient partnership necessary to facilitate selfcare. Agustin enjoined doctors to accept that “any person seeking healthcare should be treated … as customers” who deserve efficient and convenient service. ‘The self,’ ‘stress’

and ‘fiscal constraints’ were also highlighted alongside customer displeasure as deterrents. Enablers of self-care behavior were also extracted from the data: ‘the self as an enabler,’ ‘help from others,’ ‘the healthcare provider enabler,’ ‘spirituality,’ and ‘the environment’ or ‘the therapeutic milieu.’ When enablers dominate over deterrents, Agustin argued that effective self-care result and good outcomes and successful disease management are expected. Agustin placed the diabetes nurse educator in a position instrumental to dealing with these enablers and deterrents to selfcare. He recommended that nurses should constantly assess for these factors, especially among newly diagnosed patients. He pointed to quantitatively determining relationships between specific enablers or deterrents and long-term glycemic control and quality of life as a direction for future research.

24

November 2012

Philippine Focus

Use tap water for drinking, says DOH
Dr. Yves Saint James Aquino

T

he Department of Health-Center for Health Development-National Capital Region director Eduardo Janairo encouraged Metro Manila residents to use potable tap water for drinking instead of bottled water. “Water coming from our two concessionaires namely the Maynilad Water Services, Inc. (MWSI) in West Manila and the Manila Water Company, Inc. (MWCI) in East Manila are providing quality and sanitary safe potable water. The water from these two facilities is undergoing a monthly examination conducted by the Metro Manila Drinking Water Quality Monitoring Committee (MMDWQMC) to ensure its safety for the welfare of metro residents,” said Janairo. The health department is aiming to restore the people’s trust in the quality of tap water in Metro Manila, essentially decreasing its residents’ dependence on bottled water.

‘‘

Water conservation is our health safe

the first step in keeping

A report released last September 7, 2012 by the Metro Manila Drinking Water Quality Monitoring Committee (MMDWQMC) said that the water supplied by Manila Water and Maynilad at the time of sampling done last August 2012 was in compliance with the 2007 Philippine National Standards for Drink-

ing Water based on the microbiological and physio-chemical examinations. Drinking water in the MWSS distribution system was Safe and of Sanitary Quality with adequate residual chlorine of 0.3 parts per million, pronounced the committee. According to DOH, out of the 1,284 water refilling stations monitored in Metro Manila for the month of August 2012, 1,242 passed the potability standards set by PNSDW (42 or 3.3% failed). Janairo advised that consumers should look for the monthly microbiological quality results posted in refilling stations, ensuring that the water is safe and potable. “The safety of our water is everyone’s responsibility. As the concessionaire’s accountability ends with the meter, so does our responsibility begins. We should periodically check for leaks and illegal connections in our pipelines and take time to report them. Water conservation is the first step in keeping our health safe,” concluded Janairo.

25

November 2012

Philippine Focus

WHO calls for more action against malnutrition
Gabriel Angelo Sembrano

T

he World Health Organization (WHO) emphasized that expanded and sustainable interventions for proper nutrition in the Western Pacific Region is more than necessary. This call for action was delivered by WHO Regional Director for the Western Pacific Dr. Shin Young-soo during a meeting in Hanoi, Vietnam last September 24 to 28, 2012, with the Regional Committee, WHO’s governing body in the region composed of 27 countries and areas in the Western Pacific. “There is no room for complacency as the levels of maternal and young child undernutrition continue to be too high. At the same time, the rising rates of obesity and non-communicable diseases represent an epidemic – one that is growing fast in our region,” Shin emphasized. Shin acknowledged that the double burden of malnutrition could hamper the economic growth of member states. He added that appropriate nutrition starting at the earliest stages of life is a very important step in ensuring proper physical and mental development that would result in long-term benefits and optimum productivity. Shin also stressed that efforts should not only focus on the problems of overnutrition as what many countries do in the western pacific, but also on undernutrition and micronutrient deficiencies since these continue to plague the region. He also pointed out that there is a need to expand areas for action, to

identify targets and priority actions in health and other sectors, and to adopt a time frame and indicators for monitoring. As an answer to this call, the Regional Committee pledged to expand and sustain cost-effective nutrition programs that aim to prevent more than 100,000 under 5-yearold child deaths per year in the region. In addition, the regional committee is also set to endorse a resolution that would scale up nutrition based on the WHO Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition.

There is no room for complacency as the levels of maternal and young child undernutrition continue to be too high
This resolution calls for an increase in investments for nutrition interventions from 2012 to 2015. This would substantially decrease the double burden brought about malnutrition and other related mortalities and morbidities. Moreover, the plan seeks to increase exclusive breastfeeding and to stop the rapid rise of obesity among children. The WHO also intends to augment its efforts in pushing ‘Scaling Up Nutrition,’ a movement composed of multiple stakeholders focused on fighting hunger and undernutrition using cost-effective interventions.

‘‘

26

November 2012

Philippine Focus

MARKET WATCH
FACETS presents effective treatment for epilepsy and pain

T

he Philippine Neurological Association and Medichem Pharmaceuticals, Inc. hosted the Facts and Choices to Enhance Treatment Symposium (FACETS) in Nasugbu, Batangas last August 17, 2012 to discuss latest treatment strategies for neurological disorders. Dr. Troels Staehelin Jensen, a neurology and pain specialist from Denmark, discussed treatments in neuropathic pain, with emphasis on an- Medichem and PNA representatives presenting certificates to Dr. Jensen and Dr. Perucca (sixth and seventh from left ticonvulsants like gabapentin. According to Jensen, numerous studies have established the effectiveness of gabapentin in treating diabetic neuropathy, postherpetic neuralgia and other neuropathic pain syndromes. Dr. Emilio Perucca, president of International League Against Epilepsy in Italy, discussed treatment options in epilepsy. He presented studies on available anti-epileptic drugs that remain effective and well tolerated. For example, valproic acid, which is considered broadspectrum, has been proven to be more efficacious than lamotrigine and topiramate in treating generalized and unclassified epilepsies and newly diagnosed absence epilepsy.

Diabetes societies launch first nutrition algorithm

S

even diabetes societies launched the first Philippine-specific diabetes nutrition algorithm for prediabetes and diabetes management, which aims to help health providers incorporate nutritional strategies in diabetic therapy. “The benefit of the new algorithm is that it will systematize the way we doctors advise our patients on how to lose weight by an overall lifestyle change including exercise and physical activity,” said Dr. Cecilia Jimeno, vice-president of PSEM. The seven societies included the Philippine Society of Endocrinology and Metabolism (PSEM), Diabetes Dr. Jimeno Philippines, Philippine Center for Diabetes Education Foundation, Inc., Institute for the Study of Diabetes Foundation, Philippine Association for the Study of the Overweight and Obesity, Philippine Society of Diabetes Educators and the Nutritionist Dietitians Association of the Philippines. The task force based the algorithm on extensive review of clinical practice guidelines, medical literature and expert opinions.

27

November 2012

Philippine Focus

MARKET WATCH
Shoe safari celebrates shoe fashion for the whole family

R

es|Toe|Run, which sells the best international shoe brands, recently came out with a whole-day event showcasing various fun family activities. One of the highlights of the day’s festivities is the Shoe Safari Contest wherein participating families had to design and decorate their very own artwork into a cosplay costume featuring one of the eight safari animals at the event. They can choose from making a zebra, crocodile, tiger, bird, leopard, fish, giraffe, or a bee. Quite a daunting task, but the kids were surely up for the challenge urging their family members to do their best and win the grand prize. Prizes at stake for the Shoe Safari Contest were P10,000 plus 8,000 worth of gift certificates for the 1st prize, P8,000 plus 5,000 worth of gift certificates for 2nd, prize, P5,000 plus 3,000 worth of gift certificates for the 3rd prize, and a bunch of consolation prizes.

T

Robotic cleaner works independently

he Neato XV-11 is a lightweight, robotic vacuum cleaner that helps keep the house clean on its own. It is recognized as the most powerful robotic vacuum in the market, Neato thoroughly cleans different floor types, including carpet, tile,hardwood, and more. The vacuum cleaner operates by a press of a button. With its laser sensors, it maps everything in a room to clean in a pattern of straight, overlapping lines, avoiding obstacles along the way, such as tables and stairs. Once the batteries are low, it takes care of itself by returning to its base to recharge. And once fully charged, it will return where it left off. The smart robotic cleaner also allows for setting of schedule to automatically clean at the time set. Neato Vacuum is exclusively distributed by Focus Global, Inc. For inquiries, call (02) 634-8587.

28

November 2012

Philippine Focus

MARKET WATCH
Invida launches new pain treatment

I

nvida, local subsidiary of Menarini, recently launched dexketoprofen trometamol, which promises to provide rapid and efficacious pain relief with less gastrointestinal side effects. The molecular structure of dexketoprofen trometamol is the key to its pain-relieving potency, speed of action and tolerability, said Dr. Maaliddin Biruar, director for Medical and Scientific Affairs, Invida Philippines, Inc. Guest speakers during the media launch included Prof. Magdi Hanna, clinical director of Analgesics and Pain Research Unit in London, and Dr. Ester Penserga, a rheumatologist with the Philippine General Hospital. Available in tablet and parenteral formulation, dexketoprofen trometamol is indicated for pain of mild to moderate intensity, such as musculoskeletal pain, dysmenorrhea, postoperative pain, low-back pain and renal colic.

LifeScience’s 3-step medical prevention

L

ifeScience Center for Wellness and Preventive Medicine, a pioneer in preventive care and customized health management in the country, involves a three-step program to put Filipinos on the right track to wellness. Through Consultation, Testing and Treatment, LifeScience is able to accurately identify current state of wellness and design a customized Preventive Wellness Program that will allow their patients to experience being healthy in another level and live in optimum health. “LifeScience gives Filipinos, who truly value their wellness, an opportunity to take their health to a new level. By simply being proactive about our health, we Dr.Valdecanas are already doing something to ensure our graceful aging,” said Dr. Ben Valdecanas, Medical Director of LifeScience Center for Wellness and Preventive Medicine. More information on LifeScience is available at www.lifescience.ph. For inquiries, LifeScience can be reached at +632 828-LIFE (5433).

30

November 2012

Conference Coverage

48th Annual Meeting of the European Association for the Study of Diabetes, 1-5 October, Berlin, Germany

Stroke risk high in diabetes patients
Alexandra Kirsten

T

ype 2 diabetes is associated with an increased risk of stroke in the long term, suggests new research. A recent large-scale study involving 1,334 patients with type 2 diabetes found a cumulative stroke incidence of 12 percent over a 10year follow-up period. “The morbidity and mortality due to stroke in persons with type 2 diabetes mellitus is 3 to 4 times higher than in the general population,” explained study author Dr. M. Bernas from the department of internal diseases and diabetology at Warsaw Medical University, Warsaw, Poland.

Type 2 diabetes has been shown to be a long-term risk factor for stroke.

‘‘

The morbidity and mortality due to stroke in persons with type 2 diabetes mellitus is 3 to 4 times higher than in the general population

The study patients, who were all attending the same outpatient diabetic clinic, included 597 men and 737 women, and had an average age of 62.6 years and a mean duration since diabetes diagnosis of 9.4 years. Clinical determinants such as BMI, blood pressure, fasting and postprandial glycemia, cholesterol, triglycerides, creatinine, albuminuria, and co-existing complications and co-morbid states, were recorded at baseline and every year during the 10-year study period. Morbidity and mortality due to stroke were determined and correlated with poten-

tial risk factors every year separately and as a cumulative value for the whole period. At baseline, 62 patients (4.6 percent) had a previous history of stroke. In the 10-year period, 135 new episodes of stroke (in 7.5 percent of patients) were observed. The cumulative incidence of stroke was 12.1 percent, which equated to 10.8 cases per 1,000 patient-years. The cumulative mortality due to stroke was 11.0 percent. Statistically significant risk factors included age (95% Cl 1.03-1.07; P<0.001), fasting glycemia (95% Cl 1.17-3.39; P<0.05), daily albuminuria (95% Cl 1.02-4.06; P<0.05), atrial fibrillation (95% Cl 1.39-6.09; P<0.01) and smoking (95% Cl 1.17-3.00; P<0.01). These are “the main objectively established clinical risk factors for stroke,” summarized Bernas. This information should be taken under consideration in building up an individual plan of stroke prevention since “the efficacy of the prevention of stroke stands up as the ‘hot’ problem in diabetes mellitus care”, she concluded.

31

November 2012

Conference Coverage

48th Annual Meeting of the European Association for the Study of Diabetes, 1-5 October, Berlin, Germany

Insulin infusions beneficial in diabetics post-stroke
Alexandra Kirsten

P

atients with type 2 diabetes who experience an acute episode of stroke seem to benefit more from continuous intravenous insulin infusions than from intermittent subcutaneous injections. “Hyperglycemia is associated with [a] worse outcome in stroke patients,” said Leonid G. Professor Strongin from the State Medical Academy, Nizhny Novgorod, Russia. “The benefits of intravenous infusions for blood glucose control in patients with stroke and type 2 diabetes mellitus are proved at a target glucose level less than 7 mmol/L, but it is not so obvious for the more acceptable range of 7.8-10 mmol/L”, he explained. Strongin and colleagues conducted a clinical study to compare the efficacy and safety of the two different insulin delivery methods in patients with type 2 diabetes who had experienced a stroke. A total of 73 patients were subdivided into two comparable groups within 24 hours of the stroke event, with one group assigned to receive continuous insulin infusions and the other intermittent subcutaneous insulin injections, in order to achieve blood glucose levels between 7.8 and 10 mmol/L. Overall, 97 percent of the patients in the insulin infusion group achieved the glucose tar-

get compared with only 71 percent of those in the injection group (P=0.012). The mean daily glycemia level was 8.7 mmol/L in the infusion group and 9.7 mmol/L in the comparison group (P=0.025). Additionally, the infusion group reached the target glucose levels faster (2-3h vs. 3-6h, P=0.0019) and showed a smaller amplitude of fluctuations of glycemia (0.95 mmol/L vs. 5.3 mmol/L, P<0.01). The frequency of hypoglycemia was significantly lower in the infusion group than in the comparison group (9 percent vs. 22 percent, P=0.037). Patients in the basal group presented with better scores in the Barthel Activities of Daily Living Index (BADLI) at the time of discharge (45 vs. 20 points P<0.01) and after 6 months (62 vs. 47, P=0.006). However, there were no significant differences in hospital mortality between the groups: in the infusion group 25 percent of the patients died, in the control group 32.4 percent died (P=0.32). “Glucose control using continuous intravenous insulin infusions has advantages in regressing neurological deficit, improving functional recovery and decreasing risk of hypoglycemia”, concluded Strongin. But, “the impact of routes of insulin administration on 6-month survival could not be proved.”

32

November 2012

Conference Coverage

48th Annual Meeting of the European Association for the Study of Diabetes, 1-5 October, Berlin, Germany

Exercise lowers CV risk in diabetics
Alexandra Kirsten

A

new study has reported that leisure-time physical activity (LTPA) can significantly reduce the risk of cardiovascular (CV) events in patients with type 2 diabetes. Dr. Björn Zethelius and colleagues from Uppsala University in Uppsala, Sweden reviewed data on leisure-time physical activity from 15,462 patients with type 2 diabetes registered in the Swedish National Diabetes Register (NDR). In their study, patients were grouped as either “low physical activity” (no regular exercise or exercise once per week) or “regular exercise” (between three times per week and daily exercise). If a patient died during the course of the study, his or her last recorded physical-activity level was used for the analysis. The yearly recorded data showed that regular exercisers were significantly less likely to have a cardiovascular event or to die either from cardiovascular disease or any other cause. The level of LTPA was related to fatal CV outcomes and all-cause mortality independently of conventional CV risk factors in type 2 diabetes. An increased LTPA level during the follow-up seemed to lower both CV risk and mortality in diabetic patients. Those in the study who reported doing little or no physical activity at baseline but who managed to increase their regular exercise to at least three times per week by the end of the study period (average 4.8 years) had even greater benefits. Compared with individuals who did not improve their exercise habits, the number of CV-related deaths among diabetics who increased their exercise levels fell by 67 percent (95% CI 0.17-0.60). Rates of all-cause mortality were reduced by

It’s never too late to increase your physical activity, a recent study suggests

almost the same degree (95% CI 0.25-0.49). “In general, diabetics are considered to be less likely to engage in a regular exercise program than the general population,” stated the researchers. However, approximately 1,800 patients moved from a low physical-activity category into a higher physical-activity level over the course of the study. “We consider physical activity and dietary advice as the basal treatment for diabetes, and when it fails, different types of pharmacological treatment are added,” Zethelius explained. “But what this study shows is that it’s never too late to increase your physical activity. Even when you are on medication, if you increase your physical activity, you will lower your risk for cardiovascular diseases.”

Sponsored Symposium Highlights

Smashing the ABCs of IBS

“Irritable Bowel Syndrome: The Mind, Gut and More”
The Philippine Society of Gastroenterology (PSG) in partnership with Invida Philippines, Inc. held a Grand Symposium at the SMX Convention Center, Mall of Asia, Pasay City last August 22, 2012. The one-day program emphasized current concepts regarding the management of Irritable bowel syndrome (IBS). Guest speaker Professor Guy Boeckxstaens conducted a lecture on IBS entitled “IBS: The Mind, Gut and More”. Local experts in the field of Gastroenterology also attended the symposium and discussed both traditional and novel concepts in the management of IBS. The symposium also highlighted the use of Otilonium bromide (Spasmomen®, Invida Philippines, Inc.), a spasmolytic that shows promising results in the treatment of IBS.

rritable bowel syndrome (IBS) is a functional bowel disorder in which abdominal pain or discomfort is associated with relief after defecation or a change in bowel habit. There are also features of disordered defecation.1 It is a multifactorial disorder and diagnosis is primarily symptom-based.2,3 Although the global prevalence data is far from complete, it is estimated that 10% to 15% are affected in Western countries, while Asian prevalence varies from 0.8% to 15.9%. It is clear however, that the occurrence of IBS is increasing in the Asia-Pacific region, particularly in countries with developing economies.4 The symptom pattern of IBS is characterized by different pathophysiological mechanisms ranging from central to enteric nervous system (CNS-ENS) dysregulation, visceral hypersensitivity, psychological factors, altered gut flora and mucosal immune activation (Figure 1).2 The disease model includes several factors that may start as early as perinatal life and persist or be compounded by other causes until late into adulthood.5 Studies show that particular triggers such as postsalmonella infection and psychosocial factors may increase the risk of developing IBS (relative risk [RR] as high as 4.8).6,7 Figure 1. Different Pathophysiological Mechanisms Leading to Symptom Pattern of IBS 2

I

Figure 2. Meta-Analysis of High-Quality Studies Evaluating Spasmolytics in IBS16 GLOBAL ASSESSMENT OF EFFICACY OUTCOME
Meta-analysis of 17 high-quality trials

Drug Pinaverium bromide Cimetropium bromide SPASMOMEN® Mebeverine Hyoscine

Treatment Control OR n/N n/N (95% CI Random) 19 / 25 30 / 48 17 / 25 28 / 47 1.5 1.1 1.9 0.4 1.3 1 10 100

Prof. Guy Boeckxstaens,
MD PhD Professor, Department of Gastroenterology, University of Leuven, Belgium Associate Editor, Gut

148 / 317 102 / 325 6 / 40 12 / 40

106 / 182 91 / 176 0.01 0.1

Favors placebo

Favors treatment

OR, odds ratio Global assesment means assessment of patients’ wellbeing which includes reduction of the abdominal pain intensity and frequency, abdominal distention and satisfied bowel movement. Adapted from Lesbros-Pantoflickova 2004

References: 1. Longstreth GF, et al. Gastroenterology 2006. 2. Simrén M. Gastroenterology 2009. 3. Boeckxstaens G, PSG Grand Symposium, 2012. 4. World Gastroenterology Association, 2009. 5. Mayer EA, et al. N Engl J Med 2008. 6. Mearin F, et al. Gastroenterology 2005. 7. Spiller R, Garsed K. Gastroenterology 2009 . 8. Manabe N, et al. Neurogastroenterol Motil 2010. 9. Fukudo S, et al. Gut 1998. 10. Mertz H, et al. Gastroenterology 1995 11. Akbar A, et al. Gut 2008. 12. Barbara G, et al. Gastroenterology 2007. 13. Gecse K, et al. Gut 2008. 14. Manabe N, et al. Curr Gastroenterol Rep 2010. 15. Ford AC, et al. Gut 2009. 16. Lesbros-Pantoflickova D, et al. Aliment Pharmacol Ther 2004. 17. Jones J, et al. Gut 2000. 18. Clavé P, et al. Aliment Pharmacol Ther 2011.

OB is a spasmolytic that modulates the entry and release of calcium from the sarcoplasmic reticulum, thereby inhibiting smooth muscle contractions. It can also reduce pain perception by blocking the hyperalgesic effect of stimulated neurokinin-2 receptors on afferent nerves, increasing the threshold of pain for pressure and distention. Only approximately 1% of the drug is absorbed into the systemic circulation. Hence, it is virtually devoid of cholinergic side effects while effectively inhibiting intestinal smooth muscle contractions in both in vitro and in vivo preparations. OB is also proven to have similarly effective response rates in all IBS subtypes (mixed, with constipation and with diarrhea).3 Since IBS is a chronic disease, relapse is a common problem after the end of therapy.17 Compared to placebo, studies proved that OB can provide prolonged symptom-free intervals even at the end of treatment (Figure 3).18 Hence, symptom relapse is often delayed compared to other IBS treatments.3 Unlike healthy individuals, IBS patients have both neuromuscular and sensory dysfunction leading to uncomfortable abdominal symptoms. Research shows that motor responses among IBS subjects are significantly higher compared to healthy subjects exposed to the same amount of stress (in the form of corticotropin-releasing hormone concentration) over the same duration of time.8,9 Approximately 60% of IBS patients also exhibit visceral hypersensitivity.10 This observation is further reinforced by microscopic evidence of marked inflammation in IBS-afflicted intestines.11 Consequently, inflammation seems to be a predominant factor for the neuromuscular and sensory dysfunction seen in IBS. Mast cell activation, in particular, is increased and appears to be more activated in such a disease.12 Another mechanism under investigation is the change in the normal intestinal microbiota among IBS patients. Dysbiosis in the intestinal flora may lead to increased mucosal permeability leading to abdominal symptoms.13 Such findings lead to the possibility of using probiotics and antibiotics in the treatment of IBS.14 The standard of care for IBS involves a multifactorial approach. This includes dietary and lifestyle measures, and the use of spasmolytics and/or laxatives and antidiarrheal agents. Adjunctive treatment to address the central or peripheral nervous control of symptoms may also be employed using antidepressants, psychotherapy or even hypnosis. A meta-analysis by Ford et al in 2009 favored the use of tricyclic antidepressants and selective serotonin reuptake inhibitors in IBS. However, larger studies are needed to establish their effectiveness.3,15 All of these treatments are focused on reducing the bothersome abdominal symptoms of IBS.3 Pharmacologic therapy provides relief from the most predominant symptoms of IBS: diarrhea or constipation and abdominal pain.1 A metaanalysis of 17 high-quality clinical studies show that the spasmolytic myorelaxant Otilonium bromide (OB) produces effects that are significantly different from those of other spasmolytic drugs (Figure 2).16 Figure 3. Prolonged Symptom-Free Interval with Otilonium Bromide Compared to Placebo After End of Treatment18
PRODUCT-LIMIT SURVIVAL FUNCTION ESTIMATES

1 Survival probability 0.8 0.6 0.4 0.2 0
Log rank p=0.0379

Otilonium bromide Placebo

0

2
1 2

4

Weeks
Event 66% (54) 76% (60)

6
Censored 34% (28) 24% (19)

8
Median 5.000 1.000

10
Survival (95% CI) (3.000 - 8.000) (1.000 - 4.000)

No. of subjects 82 79

Where: Relapse = at least 2 episodes of abdominal pain per week or the use of rescue medication

Editorial development by UBM Medica. The opinions expressed in this publication are not necessarily those of the editor, publisher or sponsor. Any liability or obligation for loss or damage howsoever arising is hereby disclaimed. © 2012 UBM Medica. All rights reserved. No part of this publication may be reproduced by any process in any language without the written permission of the publisher. UBM Medica c/o MediMarketing Inc 11/F Equitable Bank Tower, 8751 Paseo de Roxas, 1226 Makati, Philippines T: +632 886 0333 • F: +632 886 0350 E-mail: enquiry.ph@ubmmedica.com Web site: www.ubmmedica.com

Although insight into the pathophysiological mechanisms of IBS is still rather limited, there is increasing interest in novel treatment approaches. Promising new compounds in the pipeline that are not yet approved for clinical use include the serotonin antagonist ramosetron, heatstable enterotoxins and linaclotide, k-opioid agonists and the antibiotic rifaximin. Data from all these coupled with the current standard of care will hopefully lead to better treatment regimens in the near future.3

34

November 2012

In Practice

Managing HFMD in primary care
Dr. K. Vijaya
Director, Youth Health Division Singapore Health Promotion Board

The Singapore Health Promotion Board (HPB) advocates eight target areas for effective hand washing (Box). Diagnosing HFMD Primary care physicians need to pay close attention to symptoms to ensure that patients are diagnosed early so that infected children are prevented from spreading disease to others in the school. The burden of HFMD is likely to be concentrated within young, school-going children, but rates may vary. For example, the number of HFMD cases in Singapore reached a record high of 1,687 in May 2012, which far exceeded the epidemic level of 780 cases a week. The incubation period of HFMD lasts approximately 1 week and patients may only present with a sore mouth or throat. Therefore, symptoms may not be apparent initially and early symptoms may be mistaken for other illnesses. In addition to looking out for symptoms, physicians can also check if there are other cases of HFMD within the family or in the school the child attends. A child with HFMD usually presents with the following symptoms: • Fever for 2-3 days • Sore throat and runny nose • Rash (flat or raised red spots, some with blisters) on the hands (especially the palms), feet, and occasionally on the buttocks, arms and legs • Mouth ulcers • Vomiting and diarrhea • Tiredness and weakness A child is infectious throughout the duration of the illness.

H

and, foot and mouth disease (HFMD) is a common viral infectious disease that affects all age groups, but young children are especially susceptible. HFMD can be easily spread through direct contact with saliva, nasal discharge, feces or fluid from the blisters of an infected person. Generally, it is a mild self-limiting illness that resolves in 7-10 days. HFMD rarely recurs or persists, and serious complications are also rare. Although HFMD affects all age groups, children under the age of 5 are highly prone to infection because they interact closely with one another, in the classroom or on the playground, for example, at preschools. Human contact is one of the most common causes for infections to spread person to person. Individual cases of HFMD occur constantly but these can spiral into outbreaks affecting many children rapidly. For example, HFMD has become more prevalent in Singapore of late. Cases of HFMD infection have risen from 20,687 in 2011 to 31,590 as of September 2012. Education for prevention Primary care physicians are in the ideal position to educate parents and caregivers on the importance of hygiene and help prevent the spread of infection. Simple messages teaching parents and children the proper way to wash their hands is an effective method of preventing outbreaks.

35

November 2012

In Practice
gency department. In most cases, patients do not require follow up care. Physicians should closely monitor young children (especially infants) for development of dehydration. Rarely, patients with central nervous system manifestations of HFMD such as encephalitis or aseptic meningitis may require hospitalization. HFMD is highly contagious. A child is also susceptible to getting other infections when they have HFMD. Physicians can advise parents the following: • Keep the child away from public places. • Get everyone at home to wash their hands frequently with soap. • Keep child’s toys, books, eating utensils, towels and clothes separate from others, and disinfect them regularly • Inform the school, kindergarten or child care center as soon as possible. They can monitor other children closely and take additional precautions to prevent the spread of HFMD. • Keep the child at home until he or she is fully recovered, after the expiry of the medical certificate (MC) given by the family doctor. • Ensure that any siblings are well before sending them to the school, kindergarten, or child care center. Conclusion Primary care physicians need to educate parents and caregivers about keeping their child away from public places and schools during the infection period to avoid creating an outbreak. HFMD is present all year round in Southeast Asia, with seasonal outbreaks every year. Parents and caregivers should closely monitor their children to help prevent such outbreaks in childcare centers, kindergartens and schools.

Laboratory testing is available to isolate and identify the causative agent. However, testing is usually not necessary because HFMD diagnosis is typically based on clinical grounds. Treating HFMD There is no specific treatment for the infection other than relief of symptoms. Treatment with antibiotics is not effective or indicated as HFMD is a viral infection. Easing the patient’s discomfort and helping them recover is the priority. Physicians should ask parents and caregivers to: • Encourage the child to drink plenty of fluids • Change to a soft diet (eg, porridge, pureed fruit) if the mouth ulcers are a problem • Medications can be provided to ease the discomfort, such as paracetamol syrup to relieve fever and pain • Keep the child at home to allow plenty of rest In most cases, HFMD is mild. However, a few children who are infected with the EV71 strain of the virus can become very ill, with signs and symptoms such as: • Disorientation, drowsiness and/or irritability • Fits • Severe headache, dizziness or neck stiffness • Breathlessness or turning blue • Dehydration – this can happen due to continuous vomiting, diarrhea or pure fluid intake as a result of painful mouth ulcers. The child will be very tired, have a dry tongue and may pass very little urine. A child with any of these symptoms should be immediately referred to a hospital emer-

SPONSORED SYMPOSIUM HIGHLIGHTS

3rd Diabetes Nutrition Workshop: Optimizing Nutrition and Lifestyle Strategies for Diabetes Management in Daily Practice
On May 17, 2012, the Nestlé Nutrition Institute held its 3rd Diabetes Nutrition Workshop in Manila, Philippines. The program was moderated by Dr Aimee Andag-Silva and gathered experts in diabetes care; namely, Professor Alice Kong, Associate Professor, Department of Medicine and Therapeutics, Chinese University of Hong Kong; Dr Rosa Allyn Sy, Section Head of Endocrinology, and Director of the Diabetes Care Clinic, Cardinal Santos Medical Center; Ms Gemma Dimaano, Registered Nutritionist-Dietitian with Certifications in Pediatric & Adult Weight Management, and a Diabetes Educator; and Mr Jose Jimbo Saret, Sports Training Consultant, Philippine Olympic Committee.

Pathogenesis and lifestyle risk factors of type 2 diabetes mellitus

Figure 1. Metabolic benefits of low GI diets1 Insulin resistance β-cell dysfunction Hyperinsulinemia Low GI diets and metabolic syndrome Free fatty acids Inflammation Endothelial dysfunction Prothrombotic factors Cardiovascular risk Dyslipidemia Glycemia

Associate Professor Division of Endocrinology Department of Medicine and Therapeutics The Chinese University of Hong Kong

Professor Alice PS Kong

Type 2 diabetes mellitus (T2DM) is a multifaceted disease affecting at least 170 million people worldwide.1 Its pathogenesis is incompletely understood, though interplay between genetic and environmental factors is clearly involved. In patients with impaired glucose tolerance (IGT) or diabetes, mechanisms that normally regulate postprandial hyperglycemia are impaired by delayed and reduced insulin secretion, lack of glucagon suppression, and hepatic and peripheral insulin resistance.2 Apart from classical risk factors such as dyslipidemia, hypertension and smoking, novel risk factors for T2DM represent unmet clinical needs to be addressed in the next decade. Diet is an important lifestyle factor that plays a role in the development of obesity and diabetes. When both conditions are present, glycemic goals are generally more difficult to achieve.3 Sleep is also increasingly recognized to be a novel lifestyle risk factor in T2DM and obesity. Sleep deprivation leads to increased production of stress hormones and has a harmful impact on carbohydrate metabolism and endocrine function. Its effects are similar to those seen in normal aging.3 As shown in a randomized, crossover study involving healthy male volunteers, short sleep duration was associated with decreased leptin levels, increased ghrelin levels, and increased hunger and appetite.4 Traditional pharmacologic agents for diabetes include oral antidiabetic agents, which commonly cause weight gain, as well as basal and intensive insulin therapy. Lifestyle modifications remain one of the crucial elements in the management of T2DM and is recommended by the American Diabetes Association and the European Association for the Study of Diabetes to help achieve control of hyperglycemia at all stages of management.
References 1. IDF Diabetes Atlas - Fifth edition. http://www.idf.org/atlasmap/atlasmap. Accessed July 9, 2012. 2. Weyer C, Tataranni PA, Bogardus C, Pratley RE. Diabetes Care 2001;24:89-94. 3. Kong AP, Chan NN, Chan JC. Curr Diabetes Rev 2006;2:397-407. 4. Spiegel K, Tasali E, Penev P, Van Cauter E. Ann Intern Med 2004;141:846-850.

Focusing on the value of nutrition in diabetes management, the workshop aimed to address the following learning objectives: • To briefly review the pathophysiology of type 2 diabetes mellitus and related outcomes • To discuss overall nutritional interventions for diabetes and its impact on clinical outcomes • To discuss practical considerations in lifestyle modification strategies in type 2 diabetes mellitus

Table. Glycemic index of common foods11,12
CEREAL Brown rice Medium grain white rice Glutinous rice Rice vermicelli, Kong moon Spaghetti Soba noodle White bread Whole wheat bread Cornflake All bran breakfast cereal 50 83 9 8 58 42 46 70 73 72 30 88 56 48 40 20 58 100 53 68

mine data and adjusting for baseline differences, glycated proteins were reduced 7.4% (CI 8.8 to 6.0) more on the low GI diet than on the high GI diet. In another study, blood pressure and dietary data were taken from 858 students aged 12 years at baseline.15 Among female subjects, each 1standard deviation increase in dietary GI, GL, carbohydrate and fructose intake was concurrently related to an increase of 1.81 (p=0.001), 4.02 (p=0.01), 4.74 (p=0.01) and 1.80 mmHg (p=0.03) in systolic blood pressure, respectively, after 5 years. High-density lipoprotein cholesterol (HDL-C) is an additional risk factor that may be influenced by dietary GI. Using data from 13,907 participants aged ≥20 years in the 3rd National Health and Nutrition Examination Survey (1988 to 1994), age-adjusted HDL-C levels were found to be inversely related to dietary GI and GL.16

Program Outline May 17, 2012 (Thursday) Pathogenesis and Lifestyle Risk Factors of Type 2 Diabetes Mellitus
Professor Alice Kong

STARCHY VEGETABLE AND BEAN Mashed potato Baked potato with skin Sweet potato Canned baked beans SUGARS AND SUGARY FOOD Fructose Sucrose (table sugar) Glucose Coke Ice cream, chocolate FRUIT Orange, whole Orange juice Banana Watermelon Lychee, canned

Nutritional Management as Component of Standard of Care for Diabetes
Dr Rosa Allyn Sy

Clinical Relevance of Low Glycemic Index Diet in Diabetes and Metabolic Control
Professor Alice Kong

Clinical relevance of low glycemic index diet in diabetes and metabolic control

Practical Considerations on Meal Planning for Diabetes
Ms Gemma Dimaano

Excess weight has been associated with significant morbidity and mortality related to hypertension, type 2 diabetes mellitus (T2DM), dyslipidemia, atherosclerosis and certain types of cancer.1 Among Asians, additional dietary factors such as frequent white rice intake may contribute to the risk of developing diabetes and other metabolic diseases.2 Traditionally, weight management programs have focused on restricting energy consumption through reduced fat and carbohydrate intake.3-6 However, low-fat, energy-restricted diets may elicit physiological adaptations that promote weight regain, leading to high failure rates in the long-term. The low glycemic index (GI) diet is a potential alternative dietary intervention for sustained weight management and glucose homeostasis, and may also play a role in improving other cardiometabolic risk factors (Figure 1).1 Glycemic index and glycemic load The concept of GI was first introduced by Jenkins and colleagues in the early 1980s as part of the dietary management of diabetes, recognizing that substantial variations in the physiologic effects of carbohydrates made their classification difficult.7,8 Interpreted in the simplest terms, foods with a low GI are digested and absorbed more slowly than foods with a high GI.9 Technically, GI is defined as the incremental area under the curve (AUC) for the blood glucose response after consumption of a food relative to that produced by a reference food such as glucose or white bread given in an equivalent carbohydrate amount (50 g or 25 g).7,10 Low GI foods are those with GI ≤55 and high GI foods are those with GI ≥70 (Table).11,12 Factors that increase GI ranking include amylopectin, cooking time and method, ripeness, temperature and alkalinity. Glycemic load (GL) is a function of a food’s GI and its total available carbohydrate content. Whereas

DAIRY AND OTHERS Skim milk 32 NUTREN Diabetes 31 (vs bread standard) 22 (vs glucose standard)
Red text, high glycemic index foods; green text, low glycemic index foods.

Given the increasing prevalence of obesity worldwide, low GI diets may need to be started even among younger patients. An ongoing 12-month, 48 randomized, controlled dietary intervention trial 57 has found a high frequency of fatty liver (73.3%), 51 prediabetes and other cardiometabolic risk factors 72 in obese Hong Kong Chinese adolescents (n=104; 79 mean age 16.7 years and 16.8 years in the low GI and control groups, respectively).17 After adjustment for age and sex, subjects in the low GI group had significant reduction in obesity indices including body mass index, body weight and waist circumference compared to subjects in the control group (all p<0.05). GI-based dietary guidelines Significant physiologic benefits can be achieved when GI is used to guide dietary interventions. Unlike a standard food pyramid which promotes minimizing intakes of oil, sugar and salt while maximizing cereal consumption, a low GI diet places refined grains, potatoes and sweets at the top of the restricted food list (Figure 2). International diabetes associations currently agree that consumption of low GI foods may play an important role in optimizing glucose control in patients with T2DM.18-20 Summary Choosing low GI foods in place of refined carbohydrates or high GI foods has a small but clinically useful effect on glycemic control in diabetic patients. Other metabolic risk factors such as hypertension and low HDL-C may also be better managed by following nutritional recommendations that incorporate GI concepts. In Asia, where white rice consumption may increase diabetes risk, early dietary intervention may be appropriate even among apparently healthy young individuals.
References 1. Radulian G, Rusu E, Dragomir A, Posea M. Nutr J 2009;8:5. 2. Hu EA, Pan A, Malik V, Sun Q. BMJ 2012;344:e1454. 3. Gibson LJ, Peto J, Warren JM, dos Santos Silva I. Int J Epidemiol 2006;35:1544-1552. 4. Thomas H. Health Educ Res 2006;21:783-795. 5. Krishnan S, Rosenberg L, Singer M, et al. Arch Intern Med 2007;167:2304-2309. 6. Villegas R, Liu S, Gao YT, et al. Arch Intern Med 2007;167:2310-2316. 7. Jenkins DJ, Wolever TM, Taylor RH, et al. Am J Clin Nutr 1981;34:362-366. 8. Ludwig DS. JAMA 2002;287:2414-2423. 9. Wolever TM, Jenkins DJ, Jenkins AL, Josse RG. Am J Clin Nutr 1991;54:846-854. 10. Hofman Z, De Van Drunen J, Kuipers H. Asia Pac J Clin Nutr 2006;15:412-417. 11. Milon H, et al. Thai J Paren and Enter Nutr 2003;14:24-30. 12. The University of Sydney. http://www.glycemicindex.com. Accessed March 20, 2012. 13. Kong AP, Chan RS, Nelson EA, Chan JC. Obes Rev 2011;12:492-498. 14. Brand-Miller J, Hayne S, Petocz P, Colagiuri S. Diabetes Care 2003;26:2261-2267. 15. Gopinath B, Flood VM, Rochtchina E, et al. Hypertension 2012;59:1272-1277. 16. Ford ES, Liu S. Arch Intern Med 2001;161:572-576. 17. Chinese University of Hong Kong. ClinicalTrials.gov Identifier NCT01278563. 18. Skyler JS, Bergenstal R, Bonow RO, et al. Diabetes Care 2009;32:187-192. 19. Mann JI, De Leeuw I, Hermansen K, et al. Nutr Metab Cardiovasc Dis 2004;14:373-394. 20. Berard LD, Booth G, Capes S, Quinn K, Woo V. Can J Diabetes 2008;32(Suppl 1):S1-S201.

Figure 2. Low GI diet EAT LESS REFINED GRAINS POTATO AND SWEETS REFINED GRAINS AND SWEETS REDUCED FAT DAIRY LEAN PROTEIN NUTS AND LEGUMES FRUITS AND VEGETABLES (cooked or dressed with healthful oil) EAT MORE
GI ranks carbohydrates based on their immediate blood glucose response (ie, glycemic quality), GL helps predict blood glucose response to specific amounts of carbohydrate food (ie, glycemic quality and quantity). Low GI diets help manage metabolic risk factors Several clinical trials have studied associations between low GI diets, obesity and obesity-related cardiovascular risk factors in children and adolescents.13 In a meta-analysis of 14 studies comprising 356 subjects, low GI diets reduced hemoglobin A1c (HbA1c) levels by 0.43% points (confidence interval [CI] 0.72 to 0.13) over and above that produced by high GI diets.14 Taking both HbA1c and fructosa-

Exercise Prescription for Diabetes and Weight Management
Coach Jim Saret

Effective Techniques in Motivating Diabetic Patients on Dietary and Lifestyle Modification
Ms Gemma Dimaano

Editorial development by UBM Medica. The opinions expressed in this publication are not necessarily those of the editor, publisher or sponsor. Any liability or obligation for loss or damage howsoever arising is hereby disclaimed. © 2012 UBM Medica. All rights reserved. No part of this publication may be reproduced by any process in any language without the written permission of the publisher. UBM Medica c/o MediMarketing Inc 11/F Equitable Bank Tower, 8751 Paseo de Roxas, 1226 Makati, Philippines T: +632 886 0333 • F: +632 886 0350 • E-mail: enquiry.ph@ubmmedica.com Web site: www.ubmmedica.com

37 November 2012 Calendar
November
2012 Scientific Sessions of the American Heart Association
3/11/2012 to 7/11/2012 Location: Los Angeles, California, US Info: American Heart Association Tel: (1) 214 570 5935 Email: sessionsadmin@heart.org Website: www.scientificsessions.org

World Allergy Organization International Scientific Conference (WISC 2012)
6/12/2012 to 9/12/2012 Location: Hyderabad, India Info: World Allergy Organization Tel: (1) 414 276 1791 Fax: (1) 414 276 3349 E-mail: WISC@worldallergy.org Website: www.worldallergy.org

8th International Symposium on Respiratory Diseases & ATS in China Forum 2012
9/11/2012 to 11/11/2012 Location: Shanghai, China Info: UBM Medica Shanghai Ltd. Tel: (86) 21-6157 3888 Extn: 3861/62/64/65 Fax: (86) 21-6157 3899 Email: secretariat@isrd.org Website: www.isrd.org

54th American Society of Hematology Annual Meeting
8/12/2012 to 11/12/2012 Location: Georgia, Atlanta, US Info: American Society of Hematology Tel: (1) 202 776 0544 Fax: (1) 202 776 0545 Website: www.hematology.org

63rd Annual Meeting of the American Association for the Study of Liver Diseases
9/11/2012 to 13/11/2012 Location: Boston, Massachusetts, US Info: American Association for the Study of Liver Diseases Tel: (1) 703 299 9766 Website: www.aasld.org

17th Congress of the Asian Pacific Society of Respirology
14/12/2012 to 16/12/2012 Location: Hong Kong Info: UBM Medica Pacific Limited Tel: (852) 2155 8557 Fax: (852) 2559 6910 E-mail: info@apsr2012.org Website: www.apsr2012.org

9th International Diabetes Federation-West Pacific Region Congress
25/11/2012 to 27/11/2012 Location: Kyoto, Japan Info: Japan Convention Services, Inc. Tel: (81) 6 6221 5931 Fax: (81) 6 6221 5939 E-mail: JCS-9idfwpr-4aasd@convention.co.jp Website: www2.convention.co.jp/idfwpr2012

Upcoming
16th Bangkok International Symposium on HIV Medicine
16/1/2013 to 18/1/2013 Location: Bangkok, Thailand Info: Ms. Jeerakan Janhom (Secretariat) Tel: (66) 2 652 3040 Ext. 102 Fax: (66) 2 254 7574 E-mail: jeerakan.j@hivnat.org Website: www.hivnat.org/bangkoksymposium

December
National Diagnostic Imaging Symposium
2/12/2012 to 6/12/2012 Location: Orlando, Florida, US Info: World Class CME Tel: (980) 819 5095 Email: office@worldclaswscme.com Website: www.cvent.com/events/national-diagnostic-imaging-symposium-2012/event-summaryd9ca77152935404ebf0404a0898e13e9.aspx

28th Congress of the Asia-Pacific Academy of Ophthalmology
17/1/2013 to 20/1/2013 Location: Hyderabad, India Info: APAO Secretariat Tel: (852) 3943 5827 Fax: (852) 2715 9490 Email: secretariat@apaophth.org Website: www.apaoindia2013.org

Asian Pacific Digestive Week 2012
5/12/2012 to 8/12/2012 Location: Bangkok, Thailand Tel: (66) 2 748 7881 ext. 111 Fax: (66) 2 748 7880 E-mail: secretariat@apdw2012.org Website: www.apdw2012.org

38 November 2012 Calendar
International Meeting on Emerging Diseases and Surveillance (IMED 2013)
15/2/2013 to 18/2/2013 Location: Vienna, Austria Info: International Society for Infectious Diseases Tel: (617) 277 0551 Fax: (617) 278 9113 Email: info@isid.org Website: www.isid.org/imed/Index.shtml

Asian Pacific Society of Cardiology 2013 Congress
21/2/2013 to 24/2/2013 Location: Pattaya, Thailand Info: Kenes Asia (Thailand Office) Tel: (66) 2 748-7881 Fax: (66) 2 748-7880 Email: apscoffice2013@apsc2013.org Website: www2.kenes.com/apsc2013/pages/home.aspx

23rd Conference of the Asia Pacific Association for the Study of the Liver
7/3/2013 to 10/3/2013 Location: Singapore Info: Gastroenterological Society of Singapore, The Asian Pacific Association for the Study of the Liver Tel: (65) 6292 4710 Fax: (65) 6292 4721 Email: apaslconference@kenes.com Website: www.apaslconference.org

62nd American College of Cardiology (ACC) Annual Scientific Session
9/3/2013 to 11/3/2013 Location: San Francisco, California, US Info: American College of Cardiology Foundation Tel: (415) 800 699 5113 Email: accregistration@jspargo.com Website: www.accscientificsession.org/Pages/home.aspx

4th Biennial Congress of the Asian-Pacific Hepato-Pancreato-Biliary Association
27/3/2013 to 30/3/2013 Location: Shanghai, China Info: Asian Pacific Hepato-Pancreato-Biliary Association Tel: (86) 21 350 30066 Fax: (86) 21 655 62400 Email: secretariat@aphpba2013shanghai.org Website: www.aphpba2013shanghai.org/

39

November 2012

Humor

“Give it to me straight doctor, should I start dating?”

“I sent your brown suit to the cleaners. It will match the mahogany casket perfectly!”

“He likes his steak and mashed potatoes intravenously!”

“At our hospital we either perform a Cesarian, or the Heimlich maneuver. Which one do you prefer?”

“This here? I cut myself shaving!”

“I wouldn't worry about it. He won't get far without lungs!”

40

November 2012

After Hours

Crater culture
Yen Yen Yip investigates the music and magic of Lake Toba in North Sumatra, Indonesia.

T

 he Batak man sits in front of a multihued display of souvenir T-shirts and ulos, the traditional cloth of North Sumatran Bataks. A twostringed mandolin is cradled in his arms. He opens his mouth to sing and reveals a row of broken teeth. With one hand clasping, moving and pressing down on alternate string positions, he strums, coaxing a twanging melody out of the mandolin to accompany his hoarse voice. The song is harsh and strangely elemental; it conjures up images of men sitting around a fire at night, drinking palm fruit toddy after a day of fishing on Lake Toba. One of the most famous features of Lake Toba is a caldera – a crater lake that was formed when a super-volcano erupted more than 69,000 years ago. The eruption blew up about 2,800km3 of material and created a colossal hole about 906m above sea level, which gradually filled with water. Tens of thousands of years later, the Austronesian people traveled to Sumatra, made their way inland and found a beautiful lake ringed with forested dusky-blue silhouettes of mountains. The ones who settled on the surrounding mountainous regions and Samosir, the island in the middle of the lake, became known as the Toba Bataks. Accounts of Batak traditions date back to the 1200s. Some customs have survived the test of time. For in-

stance, traditional music played with Batak instruments such as the two-stringed mandolin, flute and drums is still used during ceremonies and festivities. At these events, ulos – cloth weaved with Batak designs – are folded length-wise and draped over a shoulder. Some Bataks on Samosir continue to live in houses called rumah adat, built with distinctive roofs that sweep upwards on either end like buffalo horns, the gables adorned with elaborate carvings of thumbprint-like whorls and lines. Other tribal rituals, such as cannibalism, have died out. Early accounts of the Bataks’ predilection for human flesh came from the European explorer Marco Polo, who traveled to Sumatra in the 1290s and wrote about stories told to him of “man-eaters” who eat humans “stump and rump”. In the 1800s, Sir Stamford Raffles and other colonialists studied cannibalistic rituals of the Bataks and reported that human flesh was typically eaten when tribes waged war against neighboring villages and captured prisoners, or if a tribe member was accused of legal infringements such as murder, rape or theft. In Samosir, these grisly details can be recounted in full at Ambarita, a tribal village in Samosir which features a set of historic stone chairs where a judicial council would have sat to decide the fate of a prisoner. If the prisoner was condemned to execution, he

41

November 2012

After Hours
during which the bones are exhumed and cleaned, to be reinterred in a bone house that is elevated above ground to be closer to the heavens. The tomb of the Batak rajah Sidabutar rests on a hill in Tomok, a village in southern Samosir, past about half a kilometre of souvenir stalls lining a narrow meandering lane. His sarcophagus is carved in stone and sits out in the sun, bleached and silent. Legend has it that the monarch was a just and wise ruler whose affections were spurned by a Batak beauty, Anting Malela. In vengeance, the rajah cursed the woman and drove her insane through black magic. The rajah’s unrequited love persisted at his deathbed: he had a statue of Anting Malela carved to adorn his tomb. Today, the sarcophagus is the object of tourist fascination and camera clicks.

would be beheaded; the body would be disposed in the lake, but the blood collected and the liver extracted for consumption. The Bataks believed that all humans possess a tondi, or a life-soul, which can affect his or her physical well-being: a weakened tondi can lead to illness and even death. The blood and the liver, considered to be rich in tondi, were consumed to heal and strengthen the eater’s spiritual self. In 1890, the Dutch colonial government passed a law banning cannibalism. Rumors of cannibalism among the Bataks persisted until the early 20th century. Today’s Toba Bataks have mostly converted to Christianity. Brightly colored churches with steeples glinting in the sun are frequently spotted in the middle of rice paddies and agricultural fields along the dusty, empty roads of Samosir. Before the advent of Christianity, however, the Batak religious worldview was animistic. Divination and magic were commonly practised. Datuks – animistic shamans – recorded magic spells, healing charms, prophecies and other mystical notes in arcane Batak characters on pushtahas, books made of tree bark, folded and opened in concertina style. Certain burial practices have endured until today. At death, the Bataks are buried twice. It was traditionally believed that the tondi of a deceased person will vanish from the body; however, the begu, or the death-soul, remains. A priest is required to perform rituals at the first funeral to advise the begu to leave the family and the village. Reburial typically takes place about 8 years after death,

Getting There
Lake Toba is a five hour drive from Medan, the largest city in North Sumatra. Tourists can fly in to Medan through Polonia International Airport.

What to Do

• ive into the delicious cool waters of D the crater lake • ance with the locals in a traditional D Batak performance • ike the peaceful, rolling hills of H Samosir and drink in the scenery • ake a sip of palm fruit toddy T

Publisher Managing Editor Senior Editor Contributing Editors

: Ben Yeo : Greg Town : Naomi Rodrig : Hardini Arivianti (Indonesia), Christina Lau (Hong Kong), Leonard Yap, Saras Ramiya, Pank Jit Sin, Malvinderjit Kaur Dhillon (Malaysia), Dr. Yves St. James Aquino (Philippines), Radha Chitale, Elvira Manzano, Rajesh Kumar (Singapore) : Cliford Patrick : Razli Rahman, Charity Chan, Lisa Low, Donny Bagus, Joseph Nacpil, Agnes Chieng, Sam Shum : Edwin Yu, Ho Wai Hung, Jasmine Chay : Christine Chok : Minty Kwan

Malaysia

: Lee Pek Lian, Sumitra Pakry, Grace Yeoh Tel: (603) 7954 2910 Email: enquiry.my@ubmmedica.com : Marian Chua, Julie Mariano, Philip Katipunan Tel: (632) 886 0333 Email: enquiry.ph@ubmmedica.com : Jason Bernstein, Carrie Ong, Elijah Lee, Reem Soliman Tel: (65) 6223 3788 Email: enquiry.sg@ubmmedica.com : Wipa Sriwijitchok Tel: (662) 741 5354 Email: enquiry.th@ubmmedica.com : Nguyen Thi Lan Huong, Nguyen Thi My Dung Tel: (848) 3829 7923 Email: enquiry.vn@ubmmedica.com : Kristina Lo-Kurtz Tel: (852) 2116 4352 Email: kristina.lokurtz@ubm.com

Philippines

Singapore

Thailand

Publication Manager Designers

Vietnam

Europe/USA

Production

Circulation Executive Accounting Manager

Advertising Co-ordinator : Rachael Tan Published by : UBM Medica Pacific Limited 27th Floor, OTB Building, 160 Gloucester Road, Wanchai, Hong Kong Tel: (852) 2559 5888 Fax: (852) 2559 6910 Email: enquiry@medicaltribune.com

Advertising Enquiries: China : Yang Xuan Tel: (8621) 6157 3888 Email: enquiry.cn@ubmmedica.com : Kristina Lo-Kurtz, Miranda Wong, Marisa Lam, Jacqueline Cheung Tel: (852) 2559 5888 Email: enquiry.hk@ubmmedica.com : Monica Bhatia Tel: (022) 6612 2678 Email: enquiry.in@ubmmedica.com : Ritta Pamolango, Hafta Hasibuan, Sri Damayanti Tel: (6221) 729 2662 Email: enquiry.id@ubmmedica.com : Kevin Yi Tel: (822) 3019 9350 Email: inquiry@kimsonline.co.kr

Medical Tribune is published 12 times a year (23 times in Malaysia) by UBM Medica, a division of United Business Media. Medical Tribune is on controlled circulation publication to medical practitioners in Asia. It is also available on subscription to members of allied professions. The price per annum is US$48 (surface mail) and US$60 (overseas airmail); back issues at US$5 per copy. Editorial matter published herein has been prepared by professional editorial staff. Views expressed are not necessarily those of UBM Medica. Although great effort has been made in compiling and checking the information given in this publication to ensure that it is accurate, the authors, the publisher and their servants or agents shall not be responsible or in any way liable for the continued currency of the information or for any errors, omissions or inaccuracies in this publication whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. The inclusion or exclusion of any product does not mean that the publisher advocates or rejects its use either generally or in any particular field or fields. The information contained within should not be relied upon solely for final treatment decisions. © 2012 UBM Medica. All rights reserved. No part of this publication may be reproduced in any language, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise), without the written consent of the copyright owner. Permission to reprint must be obtained from the publisher. Advertisements are subject to editorial acceptance and have no influence on editorial content or presentation. UBM Medica does not guarantee, directly or indirectly, the quality or efficacy of any product or service described in the advertisements or other material which is commercial in nature. Philippine edition: Entered as second class mail at the Makati Central Post Office under Permit No. PS-326-01 NCR, dated 9 Feb 2001. Printed by Fortune Printing International Ltd, 3rd Floor, Chung On Industrial Bldg, 28 Lee Chung Street, Chai Wan, Hong Kong. ISSN 1608-5086

Hong Kong

India

Indonesia

Korea

You're Reading a Free Preview

Download
scribd
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->