May 2013

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Diabetes research failing to address prevention

CONFERENCE HPS2-THRIVE trial: Negative results for niacin

NEWS Low melatonin secretion linked to diabetes risk

IN PRACTICE Managing wrist pain

AFTER HOURS Getting around on the London Underground

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May 2013

Diabetes research failing to address prevention
Laura Dobberstein

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he prevention of diabetes is being overlooked by diabetes researchers, according to a recent study. “Our descriptive analysis found that the majority of registered [diabetes] trials involve drug therapies rather than preventative or non-drug interventions,” said study author Dr. Jennifer Green of Duke University Medical Center in Durham, North Carolina, US, and colleagues. Green and her team examined 2,484 interventional diabetes trials registered on the ClinicalTrials.gov website between 2007 and 2010, to better understand which aspects of the disease were being addressed. [Diabetologia 2013; doi:10.1007/s00125-013-2890-4] While 75 percent of the trials had a primarily therapeutic purpose, only 10 percent focused on prevention. Sixty-three percent of interventions used drugs and only 12 percent looked at modifiable behaviors. Their findings also indicated some important demographic disparities of trials, which tended to exclude children and the elderly, were often small in size and duration, did not geographically represent populations of those living with diabetes, and did not focus on significant cardiovascular outcomes like heart attack and stroke. Twenty percent of adults over age 65 have diabetes, but less than 1 percent of the trials included patients in this age group. Most trials excluded patients over 75 years of age and 30.8 percent excluded those over the age of 65. Four percent of trials targeted those under the age of 18. This low number of pedi-

atric trials may accurately reflect the proportion of people in this age group affected by diabetes. However, arguments exist as to why this group should be better represented in research. A 3 percent annual increase in type 1 diabetes currently exists among those under the age of 18. In addition, children have a higher chance of developing complications during their disease course and benefit more from better disease management than their older counterparts. The small size and duration of the trials concerned the researchers. The average length of a trial was less than 2 years. Over half of all trials had fewer than 100 participants and 91 percent had fewer than 500 participants. Complications like diabetic retinopathy, lower extremity amputation and end-stage renal disease vary among ethnic groups, making it important to include a diverse background of people in diabetes research. Study populations were overrepresented by patients from North America, Western Europe and certain Asian countries, but underrepresented by patients from other important regions such as Russia, Brazil and the Middle East. Cardiovascular complications related to diabetes have become an important research topic, particularly in relation to medication development. Yet mortality and cardiovascular complications were only reported in 1.4 percent of trials. The researchers concluded that current clinical trials on diabetes research do not adequately address disease prevention, management or therapeutic safety. The results from this study build a better understanding of ongoing research and could help direct future research activities and resources.

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May 2013

Fast foods going ‘cardio smart’
Naomi Rodrig
ublic education efforts promoting healthy lifestyle for the prevention of cardiovascular disease seem to be bearing fruit as some fast food chains are moving towards healthier menu options. At the recent American College of Cardiology (ACC) Annual Scientific Sessions in San Francisco, California, US, Subway was promoting heart-healthy meals, with detailed nutritional information about its sandwich and beverage choices. Subway was the first fast food chain to receive the American Heart Association’s (AHA) “Heart Check” certification by meeting AHA’s criteria. “Heart Check” meals contain <700 calories; <30 percent of calories from fat; low sodium, saturated fat and cholesterol; and at least 10 percent of daily value of beneficial nutrients such as fiber from fruits and vegetables, plus vitamins. Lowering salt content is a particular focus for Subway. “Having reduced the sodium content by 15 percent across our product line, we are continuing to look for new ways to reduce sodium while we relentlessly pursue an improved overall nutritional profile for every meal we serve,” the company spokesman announced recently. Furthermore, Subway’s kid’s meals now have <5 percent of calories from added sugar. “Targeting health education to the younger generation is the most effective way for future population health,” said past ACC president, Dr. Valentin Fuster, in his opening keynote lecture. Focusing on disease prevention efforts, Fuster pioneered health education programs in elementary schools in Spain and

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Brazil, which showed that children aged 4-6 years are the most likely to adopt healthy diet and lifestyle in the years ahead. Coca Cola, synonymous with sugary drinks, has also diversified in the past few years to produce a wide range of healthy beverages, including natural juices, and protein-rich or vitamin-fortified drinks. Marketed under different brand names, some of these drinks have gained popularity among health-conscious consumers, but are still far from replacing the traditional coke. Further, ACC delegates who sampled the new drinks at Coca Cola’s booth remarked that most of them are still too sweet. In addition, Coca Cola has partnered with the US National Heart, Lung and Blood Institute in supporting “The Heart Truth” campaign – a program that aims to educate people and raise awareness about heart health and provide tools and resources for heart-healthy lifestyle. Doing good for the public also makes good business sense for the food chains as consumers get more knowledgeable and conscious about their diet, demanding healthier food choices, including in fast food outlets.

strategies to empower patients with knowledge. congenital heart disease and. Key ACC initiatives to help advance cardiovascular health include data registries and their impact. inculcating healthy behaviors and considering the contributions of genetic factors and. US. growing to a total of seven registries. The college has also focused on patient-centered care and is seeking collaborations among organizations for the development of guidelines. better population health and affordable care from the perspective of both the patient and society.4 May 2013 Forum Conquering cardiovascular disease around the globe Excerpted from a keynote lecture by Dr. value and professionalism. during the 62nd Annual Scientific Sessions of the ACC. transcatheter valve therapy. both locally and globally. starting with early detection of disease. appropriate use of diagnostic modalities and interventions. first and foremost is the care of the patient with heart disease. most recently. . The ACC’s National Cardiovascular W Data Registry. California. These continually enrolling registries have more than 24 million records. Of course there are many other factors that we must consider and dedicate our efforts to. implantable cardioverter defibrillator therapy. we need to consider all the elements. quality tools and health policies. Certainly. or NCDR. National data registries provide important data on practice of medicine and patient outcomes. importantly. including interventional cardiology. management of acute myocardial infarction. held recently in San Francisco. ethnic backgrounds. and approaches to deal with public health challenges. William Zoghbi. celebrates its 15th year this year and it has become the flagship of registries. We aim for better care. These cover most areas of cardiology. The ACC’s answer to achieving this triple aim has emphasized quality. raising awareness about the impact of obesity. hen we think about overall cardiovascular care. president of the American College of Cardiology (ACC).

The outcome of the summit was a political declaration that called on the World Health Organization to establish global targets for curbing NCDs.5 May 2013 Forum research. With the data. Before reporting door-to-balloon data for treatment of acute heart attack. Our most recent partnership with the Society for Thoracic Surgery. the World Health Assembly met in Geneva in May 2012 and approved a monumental goal: a 25 percent reduction in premature mortality from NCDs by the year 2025. Many of these risk factors are the same for other NCDs. ushers in a new registry paradigm – this one for patients with advanced aortic stenosis – mandating participation for reimbursement while monitoring quality. devices and catheterbased and surgical interventions. There are 10 highest risk factors for cause of total death worldwide. many patients who need to take aspirin are not. Therefore. patient outcome and supporting research and innovation. The power of data reporting can change clinical practice and improve quality of care. most hospitals and physicians believed they were doing a great job in this type of care. many challenges remain. not only cardiovascular health. In the US. Reflecting on the application of knowledge. Even more urgent are challenges looming globally. payers and industry. Prompted by the NCD Alliance. And many are in need of better blood pressure control and cholesterol management. looking back on the impact of cardiovascular interventions and outcomes. the other main noncommunicable diseases (NCDs). overweight and obesity. It is higher than cancer. and registries show us what we are actually doing and will likely be doing in the future. thanks to advances in . physical inactivity. the United Nations had its first ever high-level meeting on NCDs in September 2011. However. This is where we need to be spreading the word about healthy living and healthy choices in the community. while science tells us what we can do. The most important is high blood pressure followed by tobacco use. although better than in other countries. with presence in Asia. guidelines tell us what we should do. and high cholesterol. This enables sharing and comparing of cardiovascular care quality between nations worldwide with the goal of improving cardiovascular care. combined. A key component of high-quality care places an emphasis on the patient. Such data also lowered the rate of inappropriate angioplasties in favor of medical treatment. high glucose. are still far from optimal. Death from cardiovascular disease exceeds that from any other disease and accounts for about one-third of total deaths worldwide. Smoking rates. The projected trends are alarming as they gradually increase for both cardiovascular disease and cancer. On one hand. respiratory disease and diabetes. excessive alcohol use. raised blood pressure. it is really gratifying to see the significant decline in cardiovascular mortality in the US over the past 40 years. salt intake. Indeed. the Middle East and South America. What is also exciting is that some of these registries have gone global. To achieve that overall goal. medications. addressing them will have a major impact on global health. the percent of patients achieving a doorto-balloon time of less than 90 minutes improved. as well as regulatory agencies. physical inactivity. the following targets were adopted: reductions in tobacco smoking.

It is crucial to establish better . As risk factors are so prevalent and traditional treatments are affordable. diabetes and obesity. We can protect population health by taking a global perspective and working together with ACC chapters and national and international organizations to reach this noble goal. there are challenges but great opportunities to reach this ultimate goal. knowing these may vary by nation. Cardiovascular disease is a global problem. Availability of essential medications to prevent heart attack and stroke was also emphasized.6 May 2013 Forum funding for the NCD movement – currently NCDs cause about 60 percent of global deaths yet receive about one percent of health funding. there is no need for new inventions globally. Going forward. So the time is now for us to act and work collaboratively. A big challenge is implementing the resolutions of various targets.

pendency. San Francisco. San Francisco.7 May 2013 Conference Coverage 62nd Annual Scientific Sessions of the American College of Cardiology. US Preventing cardiovascular disease: Do the very elderly require a different approach? Excerpted from a lecture by Dr. If you ask your patients and give them informed consent before procedures. We no longer look at just prolongation of life as a good outcome. clinical professor of Medicine. then we have the same goal for all patients. Bioengineering. they might tell you they don’t mind dying but . Janice Schwartz. They certainly have more comorbidities and those are going to influence our choices and limit our options. However. I’m also going to introduce the concept that we would like to prevent decline in de- W Regular activity in the very elderly improves quality of life and life expectancy. US. It’s obvious. we’re willing to say fewer hospitalizations and decreases of morbidity are a valid goal. But if the goal is the best therapy for each patient. I said yes. US. and Therapeutic Science at the University of California. And clearly cost limits the options – elderly women in the US have the highest level of poverty of any group. I think the individual treatment goals might differ as you have older patients. California. California. 9-11 March. held recently in San Francisco. maybe the approach should be to choose options and therapy that benefit the patient in their life span. during the 62nd Annual Scientific Sessions of the American College of Cardiology. there is no question we should be treating elderly patients differently than younger patients. hen I first thought about whether the very elderly require a different treatment approach. I’m going to define benefit as meeting the goals of the patient and improving the function or quality of life – that is a wonderful goal and cardiologists are coming around to that.

7 years to live. Prognosis calculators that weigh these indicators for the elderly might show that the odds of dying within 4 years for someone who does not have diabetes or is overweight and doesn’t have cancer or smoke but has difficulty bathing or with other activities of daily living might be 59 percent.804 patients aged they don’t want to wake up with a stroke and be dependent. as the economist Milton Friedman said: “Never try to walk across a river just because it has an average depth of four feet. Traditional risk calculators such as the Framingham risk score and the Reynolds risk score do not help decision making for the elderly. ‘‘ The challenge is. Similar risk calculators for this group include determining whether patients have been hospitalized. a 90-year-old has another 4 years to live and if you make it to 100 you will probably live another 2 years. However. recognize the importance of function and the lagtime until benefit or harm of therapies. of course. But as people get older. when we’re going to start shifting from thinking about life prolongation to quality of life and function. smoking. there is considerable variability. Data from the US Census Bureau show that an 85-year-old man might have on average 5. the 90-year-old has another five years and the 100-year-old is going to have about 2. when we’re going to start shifting to quality of life and function from thinking about life prolongation But that’s average life span and. and we can do it in the middle-aged and younger patients. The goal is prolonging their life.3 years. So if the risk factors are different. of course. should treatment be different? Treat with life span in mind As an example. So I think we have to do a better job when we come to individual decisions about our patients to try and project their life span. For women those years are even longer. managing finances.8 May 2013 Conference Coverage In an average life span for people between 70-90 years. The challenge is. and trouble pushing large objects. the presence of chronic diseases. the addition of congestive heart failure to a person with this profile would only increase the odds of dying within 4 years to 64 percent. are they receiving home care services and whether they are poor. The key concepts that provide a framework for decision making are to estimate life expectancy in the elderly and very elderly. we really have a goal of treatment. managing finances. do they have hearing impairment or weight loss. if they can read a newspaper. the things that become important are quality of life and maintenance of function. and so on – certainly much more so than heart failure. one trial compared statin therapy with placebo in 5. dressing. body mass index. Risk factors that are important in the older group are age. The 85-year-old might be living out to about 7 years. The things that drive life expectancy in this group are really the activities of daily living – bathing. and patient-centered decisions.” . sex. on average. the ability to walk several blocks. difficulty with the activities of daily living. Consider life expectancy over patient age When we think about diseases and risk factors.

[Lancet 2009. It doesn’t need to be intense exercise like it should be for cardiovascular benefit in middle-aged men. using aspirin for primary prevention of cardiac events. especially the older patient. the elderly require different approaches. the risk of death or cardiovascular events remains almost the same. The American Geriatric Society says yes. The US National Institutes of Health says regular activity improves quality of life.373:1849-1860] Here patients may not live that long so they don’t get the potential benefit. for example.9 May 2013 Conference Coverage Make exercise a priority The one thing that helps everything a patient has is exercise.7-10 years out. To conclude. 70-82 years over 4 years with a history or risk of vascular disease. using potentially inappropriate drugs with caution and advise against tight glucose control. Again. We should be the leaders in developing exercise programs that are going to benefit the whole patient. There are no shortterm adverse effects. we see aspirin reduces the risk of myocardial ischemic events. [Lancet 2002. Function and not cardiovascular risk factors have the greatest impact on life expectancy and quality of life in the very old. the treated time-to-benefit is not until 3. extends life and decreases the risk of cardiovascular disease and other illnesses and disabilities. with a higher rate of bleeding. there is a short lag-time for benefit and the benefits hit the body both above and below the waist.360:16231630] Even by the time one begins to see benefits from the statin. there is no difference in cardiovascular mortality but bleeds happen earlier and they risk hemorrhagic stroke. So I would say someone with a life expectancy less than 2 years is not going to benefit and therapy may well hurt them. according to one study. . If we also look at the evidence for aspirin for primary prevention. and does not prolong life. calling moderate control better. And we must focus on improving function with exercise and preventing the conditions that decrease function and quality of life. when picking medications for hypertension. they key considerations for the very elderly are estimated life expectancy – not age alone – lag-time to potential benefit and adverse treatment effects and burden. and certainly up to 2 years. Estimates of benefits and harms should be weighted with qualitative judgments of individuals’ values and preferences. it will certainly cost more.

5 percent. procedural complications were less common with cangrelor (3. randomized to a bolus and infusion of cangrelor or a loading dose of oral clopidogrel (600 mg or 300 mg). “all-comer trial” involving 11. [N Engl J Med 2013. myocardial infarction (MI). but it won’t be routine therapy for all PCI patients yet.10 May 2013 Conference Coverage 62nd Annual Scientific Sessions of the American College of Cardiology. Massachusetts.44). ischemia-driven revascularization and stent thrombosis by 22 percent at 48 hours post-randomization (p=0. US. doi:10. and co-principal investigator of CHAMPION PHOENIX. Unlike clopidogrel.” said first study author Dr. San Francisco. Deepak L. Cangrelor significantly reduced the primary endpoint of composite rate of death. US.4 percent vs 4. Robert Harrington of Stanford University School of Medicine in California.005) without an increased risk of severe bleeding (p=0. Bhatt from the VA Boston Healthcare System and Brigham and Women’s Hospital in Boston. ing another drug into the medical regimen. p=0. cangrelor takes effect rapidly and wears off within an hour of infusion. according to results from the CHAMPION PHOENIX* trial. Despite being a more potent antithrombotic than the comparator.002) as well as the need for rescue therapy with glycoprotein IIb/IIIa in- . Overall. non-STEMI or STEMI) or other conditions requiring urgent or elective PCI. double-blind. which allows for flexibility to initiate and stop ADP inhibition immediately in patients requiring urgent surgery or in those who develop bleeding complications.” said Dr. 9-11 March.145 patients with acute coronary syndrome (stable angina. US Cangrelor outperforms clopidogrel during PCI Elvira Manzano he new anti-clotting agent cangrelor. given during percutaneous coronary intervention (PCI). CHAMPION PHOENIX is a randomized. California.1056/NEJMoa1300815] “Cangrelor may be an attractive option across the full spectrum of patients undergoing PCI. This benefit was driven by a 20 percent reduction in the rate of acute MI and a 38 percent reduction in the incidence of stent thrombosis. there was “no bad bleeding that would be worrisome when add- T Cangrelor successfully reduced ischemic events without increased risk of severe bleeding. performed better than mainstay drug clopidogrel at reducing ischemic events. Bhatt added.

the secondary endpoint. was also less frequent with cangrelor (0. US. Drs. [N Engl J Med 2013.01).8 percent vs 1. cangrelor’s manufacturer is planning to file an approval with the US Food and Drug Administration. Moreover. the benefit in the composite efficacy endpoint was sustained in the cangrelor arm at 30 days of follow-up (p=0. Based on these results and the previous BRIDGE** trial. Texas. which experts said confirmed the end of the drug’s clinical value.” they said. Intravenous cangrelor appears to be a better strategy than oral clopidogrel for ADP blockade during PCI. noted that more than a third of patients in the study received 300 mg of clopidogrel. The incidence of stent thrombosis at 48 hours. “In the light of these findings we consider that the role of ER niacin preparations for the prevention of cardiovascular disease needs to be reconsidered. remains to be studied. sity of Oxford in the UK. both from the University of Texas Health Sciences Center at San Antonio.001). p=0. such as prasugrel or ticagrelor which are currently in use.1056/NEJMe1302504] *  CHAMPION PHOENIX: A Clinical Trial Comparing Cangrelor to Clopidogrel Standard Therapy in Subjects Who Require Percutaneous Coronary Intervention **  BRIDGE: Maintenance of Platelet Inhibition With Cangrelor hibitors (p<0. Harrington concluded. David Hillis. Whether or not it is better than other ADP-receptor blockers. in high-risk heart patients showed that the drug failed to reduce the risk of major vascular events compared with statin therapy and caused a significant number of serious adverse events in the study population.4 percent.” said lead author Professor Jane Armitage of the Univer- HPS2-THRIVE takes niacin-based therapy off the table. Richard A. laropiprant.” . “This was a disappointing result but nevertheless is a clear and reliable result. Given such concerns.01).11 May 2013 Conference Coverage In an accompanying editorial. Lange and L. doi:10. which is inferior to the 600mg dose in achieving platelet inhibition and preventing periprocedural ischemic events. the largest study of extended-release (ER) niacin plus the anti-flushing agent. “the routine use of this therapy for all patients undergoing PCI is not yet justified. HPS2-THRIVE trial: Negative results for niacin Radha Chitale R esults from the HPS2-THRIVE* trial.

the 10-15 percent benefit that Armitage said should have resulted from these lipid changes was not observed. All patients received standard lowdensity lipoprotein (LDL) lowering therapy consisting of simvastatin with or without ezetimibe.7 percent bleeding in the gut and intracranially (p=0. less well-controlled LDL cholesterol levels and patients with metabolic syndrome.29). Joseph’s Health System in Atlanta. but the absolute benefit in these patients was still small compared with the amount of adverse events.3 percent dermatological (p=0.4 percent infections. [N Engl J Med 2011. but Armitage indicated that the case for niacin appears to be closed. 0. However.7 percent. any stroke. and 0. niacin resulted in an excess of 3. which went beyond the well. Tredaptive®. It is unclear whether any therapy involving lipid manipulation. there were 31 serious adverse events per 1. which was halted more than a year earlier than planned when it failed to reduce the risk of cardiovascular events and increased risk of ischemic stroke. Spencer King.” she said. director of . and 1 percent gastrointestinal adverse events (p<0. p=0. which the current trial does not account for.8 percent new-onset diabetes.12 May 2013 Conference Coverage academic affairs at St.000 niacin-treated patients.7 percent musculoskeletal (p=0. The researchers also reported an excess of 0. including non-fatal myocardial infarction. despite niacin’s poor showing in this and other trials.365:2255-2267] Merck Sharp & Dohme Ltd (MSD) suspended global sales of their niacin/laropiprant product. it is typically used in patients with higher. 1.7 percent diabetic complications. * HPS2-THRIVE: Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events ** AIM-HIGH: Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides: Impact on Global Health Outcomes HPS2-THRIVE randomized 25. 0. notably the AIM-HIGH** trial in 2011.0008). “We were not able to identify any particular group of patients who we felt any benefits from the reduction in major vascular events would be outweighed by these adverse effects on a variety of other systems. Armitage said the trial did show a trend toward greater benefit for patients entering the trial with higher LDL cholesterol.known side effects of niacin. triglyceride reduction of 33 mg/ dL and high-density lipoprotein (HDL) increase of 6 mg/dL. noted that.9-year study. Discussant Dr.04 percent heart failure (p=0. could be cardioprotective. in January 2013. There was no difference in efficacy between niacin. 1. coronary death. Over the course of the 3.0026) serious adverse events.2 percent vs 13.05). or revascularization (13. US. The HPS2-THRIVE results are not entirely surprising given the poor results of niacin in previous trials. Georgia. as demonstrated by a similar number of major vascular events. Niacin did cause an average LDL reduction of 10 mg/dL.0001 for all).673 highrisk heart patients from Europe and China to a combination of ER niacin/laropiprant or a placebo. The most striking aspect of the trial was the excess of serious adverse events as a result of niacin therapy–events significant enough to result in hospitalization or significant illness. Compared with placebo. particularly raising HDL levels.and placebo-treated patients.0002).

and had an impact on mortality for TAVR patients. called attention to the advanced age of the patients – 84 years on average.001) and more major bleeding (31. PARTNER A included 699 patients (median age. compared with 35. surgery similar in severe aortic stenosis Elvira Manzano T ranscatheter aortic valve replacement (TAVR) remains comparable to open heart surgery in the long term in patients with severe aortic stenosis at high risk for surgery. physicians were particularly concerned about the high mortality rates. For example.” One-year results from the PARTNER A trial. Dr. California.5 percent vs 20. Patrick O’Gara of Brigham and Women’s Hospital.6 percent of those without regurgitation or trace amounts. US. Bernard Gash of the Mayo Clinic in Rochester.2 percent and 9. there was no statistical difference in the primary endpoint of all-cause mortality between the two groups – 44. US Long-term outcomes of TAVR.” The investigators said PARTNER will continue to follow up on patients for 5 years to assess durability and longer-term outcomes of TAVR. At 2 years. even mild paravalvular regurgitation was associated with increased mortality.8 percent. p=0. At 3 years. there were more major vascular complications with TAVR (12. Vinod Thourani from Emory University School of Medicine in Atlanta.8 percent with open heart surgery.3 percent.” In a press briefing following the presentation. “Future efforts should be directed toward reducing TAVR-procedure-related complications. At 3 years. “Our expectations for their outcomes need to be tempered by the context in which these procedures are offered. “We still have 44 percent mortality at 3 years. “TAVR should be considered an alternative to surgery with similar mortality and other major clinical outcomes. showed similar mortality outcomes for TAVR and surgery. but mortality rates with both approaches are high. however. Paravalvular regurgitation was also more frequent (p<0. 9-11 March. Boston. according to the updated results of the PARTNER* trial.13 May 2013 Conference Coverage 62nd Annual Scientific Sessions of the American College of Cardiology. 84. 60. San Francisco. strokes and transient ischemic attacks (TIA) were significantly higher with TAVR.5 percent vs 3. US. presented 2 years ago. p<0. Paravalvular leaks or regurgitation were persistent and fatal. respectively.6 of those with mild leaks had died.003).1) enrolled between May 2007 and September 2009 and randomized to catheterbased procedure – either through transapical or transfemoral access – or surgery. including strokes. * PARTNER: Placement of Aortic Transcatheter Valves . “What we have to learn is how better to select these patients.2 percent with TAVR and 44. While the valves appear to be durable in the long run.8 percent.” said Dr. who moderated the session.8 percent of patients with moderate-to-severe paravalvular leaks and 44. Stroke rates were also no different at 8.001). However. Minnesota.” said study presenter Dr. Georgia. The trial was extended to assess longterm outcomes and valve performance. vascular events and paravalvular regurgitation.

according to study population.8 percent.3 .14 May 2013 Conference Coverage 62nd Annual Scientific Sessions of the American College of Cardiology. p=0. California. T Different types of CABG surgery continue to show mixed outcome results. Conversely. surgical expertise are key Naomi Rodrig hree late-breaking clinical trials compared on-pump versus off-pump coronary artery bypass graft (CABG) surgery. “There was no significant difference in the primary composite endpoint of death. Germany. Bad Neustadt.2 vs 13. MI or new kidney failure in 4. Results for all components of the primary endpoint were similar between the groups at 30 days. San Francisco.2 vs 7. especially in developed countries. repeat revascularization or new renal replacement therapy within 30 days of surgery between the two arms [8. stroke. As reported previously. and there was also no significant difference in the rate of the primary endpoint at 12 months (14.” he said. p=0. there was no difference between patients receiving the off-pump and on-pump surgery at 30 days (12.752 patients scheduled to undergo CABG. requiring a heartlung machine and disposable components.1 percent. and this is equally true for both techniques. stroke. “Our data showed that CABG can be performed in the elderly population with excellent results.” reported Dr. reporting mixed outcomes. 9-11 March. US On.or off-pump surgery.74].483). On-pump CABG is less demanding surgically but more expensive.0 vs 13. the less costly off-pump or “beating-heart” procedure requires a higher degree of surgical expertise. CORONARY – the largest trial to compare the two procedures – examined the composite of death. The less costly off-pump surgery may be beneficial in developing countries. Previous trials comparing the two techniques reported conflicting results. and off-pump procedures have become less popular during the past decade. The German Off-Pump CABG in Elderly Patients (GOPCABE) study randomized 2. myocardial infarction (MI). Anno Diegeler of the Heart Center Bad Neustadt.539 patients aged ≥75 years undergoing elective.vs off-pump CABG: Patient factors. first-time CABG to on.

15 May 2013 Conference Coverage of the primary endpoint among patients receiving the off-pump procedure (9. percent.” concluded Dr. p=0. especially older ones with many other disorders or diseases. our results were similar with both techniques.028). which randomized 206 high-risk patients (EuroSCORE ≥6) to receive on. Canada. the researchers found only a transient improvement in neurocognitive function among those receiving off-pump CABG. as was quality of life. “Our study shows that surgical revascularization without using the heart-lung machine can be beneficial for high-risk patients.9 percent. p=0. the single-center PRAGUE-6 trial.” While neurocognitive decline might be more prominent with on-pump surgery. found a significantly lower rate . All investigators stressed that risk assessment and surgical expertise are key factors affecting patient outcomes. “At 1 year. a significantly higher percentage of on-pump patients required a blood transfusion (80.” suggested Lamy. Furthermore. “We now found that both on-pump and off-pump bypass have similar results even at 1 year. Czech Republic.” he said.or offpump CABG.017). p=0. of Charles University in Prague. In contrast. surgeons should tailor their surgical approach to their technical expertise and expected technical difficulty. “The rates of coronary revascularization were also similar between the groups.24).6 percent.” said lead investigator Dr. “Therefore. Jan Hlavicka.2 vs 20.2 vs 64. Andre Lamy of McMaster University in Ontario.

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the primary endpoint. In a second trial. Seventy-five percent of patients on gastric-bypass and 95 percent on biliopancreatic-diversion (p<0. BMI. Ohio. body weight and insulin resistance improved significantly in those who underwent bariatric surgery. [N Engl J Med 2012. glucose monitoring and newer diabetes drugs) prior to randomization. Francesco Rubino from Weill Cornell Medical College in New York City.001 for both) went into remission of hyperglycemia compared with none on medical therapy. 366. glucose and blood pressure also dropped significantly after surgical procedures.17 May 2013 News Surgery tops medical therapy for obese diabetics Elvira Manzano ariatric surgery improved glycemic control better than optimal medical therapy alone in obese patients with type 2 diabetes independent of weight loss.1577-1585] “Although bariatric surgery was initially conceived as a treatment for weight loss. Schauer from Cleveland Clinic. two randomized trials have shown. Average weight loss was greater after surgical procedures than after medical therapy (60 lbs vs 10 lbs). “The take home message is that surgical patients enjoyed not only significant or superior improvement in glycemic control but did so on much lower regimens of diabetic and B Bariatric surgery is a treatment option to better manage obese diabetics.008). cardiovascular medications. US. weight management. [N Engl J Med 2012.” said senior study author Dr. In the larger of two trials (STAMPEDE*). in 42 percent and 37 percent of patients who underwent gastric bypass and sleeve gastrectomy.366:1567-1576] STAMPEDE included 150 obese patients (BMI.” said STAMPEDE study author Dr. or medical therapy alone. All patients received intensive medical therapy (lifestyle counseling. compared with 12 percent in those who received intensive medical therapy alone (p=0. but increased with medical therapy alone. HbA1c levels normalized to ≤6 percent by 1 year. Philip R. US. 27-43 kg/m2) with uncontrolled type 2 diabetes randomized to Roux-en-Y surgery or sleeve gastrectomy. bariatric surgery resulted in greater reductions in fasting glucose and HbA1c levels after 2 years than did medical therapy. The study involved 60 severely obese patients with advanced diabetes randomized to . it is now clear that surgery is an excellent approach for the treatment of diabetes and metabolic disease.002 and p=0. respectively. Medication use to control lipids.

[N Engl J Med 2012. 366. “Such procedures should be considered earlier in the treatment of obese diabetics. George M.18 May 2013 News iatric surgery suggests that they should not be seen as a last resort. Drs. said the success of various types of bar- . Alberti of King’s College Hospital.” They however cautioned that larger trials of longer duration are necessary to determine durable benefits.1635-1636] Given this concern. strict diet and lifestyle interventions). or gastric bypass surgery or biliopancreatic diversion. Paul Zimmet of Baker IDI Heart and Diabetes Institute. Melbourne. STAMPEDE will follow up patients for 4 years.5 percent which is more aggressive than the American Diabetes Association standards of ≤7 percent. London. * STAMPEDE: Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently conventional medical therapy (medication. Australia and K. In an accompanying editorial.M. Both studies targeted an HbA1c level of <6.

McMullan of Brigham and Women’s Hospital. menopause. The question remains as to whether melatonin could be a modifiable risk factor for the prevention or possibly treatment of type 2 diabetes. The median urinary melatonin-to-creatinine ratio was 67 ng/mg among high melatonin secretors compared with 14.3 cases among high-secreting women. medium and high melatonin secretors. [JAMA 2013. Prior studies have shown that insulin resistance and type 2 diabetes is associated with lossof-function mutations in melatonin receptors. which was higher than the median ratio of the diabetic group (28.3 cases of diabetes per 1. hypertension.4 ng/mg among the low-secretion group. said the results translated to 9. lifestyle and location factors.2 times more likely than high melatonin-secreting women to develop type 2 diabetes. melatonin levels tend to be low throughout the day. according to a recent observational study. US. Women with low levels of nocturnal melatonin were 2. Women in the diabetes group were divided into three groups of low. including men and other ethnic groups. history of diabetes. plateau while sleeping and drop upon waking. .000 patient-years among low-secreting women compared with 4. 370 women developed type 2 diabetes and the researchers matched these subjects with an equal number of controls. The researchers controlled for body mass index. rise in the evening.3 ng/ mg.2 ng/mg). The median urinary melatonin-tocreatinine ratio among controls was 36. however the wide variation in melatonin secretion levels makes unraveling the connection difficult. use of beta blockers or non-steroidal anti-inflammatory drugs and diabetes biomarkers. Boston. Over 12 years. Further studies on different populations. W Melatonin may play a role in the pathogenesis of type 2 diabetes. Lead researcher Dr. Massachusetts. The case-controlled study drew data from a cohort in the US Nurses’ Health Study and included women who provided urine and blood samples at baseline in 2000. may also be indicated.19 May 2013 News Low melatonin secretion linked to diabetes risk Radha Chitale omen who produce low levels of nocturnal melatonin are more than twice as likely to develop type 2 diabetes independent of other major diabetes risk factors. Ciaran J. Normally. endogenously through dark exposure or exogenously through oral supplements.309:1388-1396] The researchers measured melatonin secretions indirectly using creatinine as a proxy marker. McMullan said the data suggests that endogenous levels of melatonin may be part of the pathogenesis of diabetes. the researchers noted.

000 (S$174. the researchers said. in real time or saved for later access. without scheduling unnecessary visits. . including allowing patients to be more independent and spend less time actively seeking monitoring or care. particularly for patients with chronic diseases. little quality data exist on the association between outcomes and costs. Doctors can monitor patients’ blood pressure or glucose levels. analysis showed that telehealth would probably be effective. for example. “Management of people with long-term conditions is under the spotlight. heart failure or diabetes.346:f1035] Patients were randomized to telehealth intervention (n=534) or to usual care (n=431). a new study from the UK shows. QALY for telehealth plus usual care was £92. Telehealth was designed to have a number of benefits to both patient and doctor. Even factoring in an 80 percent reduction in equipment costs and higher working capacity. These types of measures were thought to reduce healthcare costs through fewer doctor appointments and avoiding unnecessary treatments in favor of more effective ones. given the rapidly growing prevalence of such conditions in aging populations. These patients had to have at least one of three chronic diseases: chronic obstructive pulmonary disease. which is well above the T UK National Institute for Health and Clinical Excellence threshold of £30.20 May 2013 News Telehealth not cost-effective. They added that the study raises further issues such as targeting telehealth towards specific subgroups and the effects of livelihood and demographics on telehealth efficacy and costs that should be reviewed in subsequent analyses. [BMJ 2013.000 (S$57.” the researchers said. as well as telephone support. to 61 percent for a willingness to pay £30. A group of 965 patients from a larger telehealth trial were eligible for inclusion in this questionnaire study on health outcomes.000). during which healthcare professionals could also monitor and track vitals.000). “The QALY [cost per quality adjusted life year] gain by patients using telehealth in addition to usual care was similar to that by patients receiving usual care only. and added to the overall costs for patients that received it. study shows Radha Chitale elehealth may not be the cost-saving model of care it’s been touted as.000 per QALY. and total costs associated with the telehealth intervention were higher. However.” the researchers said. Quality of life was no different for chronically ill patients who tacked telehealth measures onto their standard supportive care compared with similar patients who received usual care. Telehealth encompassed digital telemonitoring of patient vital signs.

Follow-up interviews were subsequently conducted by telephone when the child was 1. The authors speculated that frequent moves may disrupt a child’s socio-emotional development. Kathleen Ziol-Guest. depression.12105] At the 5-year assessment. and poverty was defined by the official federal threshold.21 May 2013 News Frequent home relocations linked to behavioral problems in some children Laura Dobberstein M oving to a new home more than three times in the first 5 years of life may increase attention and behavioral problems in economically disadvantaged children. socioeconomic status and parental education level and other demographics were examined. and colleagues. Of those defined as having residential instability. Ithaca. postdoctoral associate at Cornell University.810 American children born between 1998 and 2000 from an existing study on new parents and the welfare of their children. or even due to evictions and foreclosures. Ziol-Guest and her team examined data of 2. Social networks may also be disrupted. greater rates of high school dropout.” they explained. anxiousness. Residential instability was defined as moving at least three times in the first 5 years of a child’s life. vocabulary and word identification tests determined lan- guage and literacy outcomes and a checklist monitored behavioral difficulties. Residential instability was linked to attention problems. While some families choose to move because they are dissatisfied with their old neighborhood or home. 44 percent were below the poverty threshold. aggressiveness and hyperactivity among 5-yearolds living in poverty. 3 and 5 years of age.” noted study author Dr. US. doi: 10. Child gender. creating an extra challenge for children to make new friends. poorer emotional and behavioral outcomes and lower levels of educational attainment. Previous studies have linked frequent moving to reduced academic performance. The parents were interviewed at the hospital shortly after giving birth. others have to move in search of work. “Low-income families may move for different reasons than higher-income families. [Child Dev 2013. less expensive housing. race. an evaluation of the home environment and an appraisal of the child’s health and development. according to a recent US study. Language and literacy outcomes and those who were not categorized as poor were not affected by moving. Seventy-seven percent of the children in the study had experienced at least one move and 29 percent were residentially instable. In-home assessments were also done when the child was 3 and 5. . The assessments included an interview with the mother.1111/cdev. Feelings of frustration or anger may be displayed as behavioral problems while test scores are less directly affected. “Developmental psychologists have shown that the home environment is one of the most important influences on young children’s school readiness. New York.

” adding that not all children experiencing multiple moves will have behavioral issues. and author of Happy. Sad. US.” said Im-Wang. Sunny Im-Wang. which also impacts children’s behavior due to family’s stress. Dr.22 May 2013 News for young children. Speaking to Medical Tribune. “With lower-income families. frequent changes and inconsistent environment [are] not good . pediatric psychologist and school psychologist in San Francisco. & Everything In Between: All About My Feelings said: “Usually. the stress of financial issues puts burden on the family. California.

” said Beinaime. The study examined vitamin D status in relation to early mortality or transplant loss.” Bienaime and his team studied 634 patients who underwent a kidney transplant to better understand vitamin D levels at 3 months after transplantation. “Vitamin D is a critical hormone controlling mineral homeostasis. The patients were evaluated over a 2. K Blood and urine samples were analyzed for content and biopsies were examined for tubular atrophy and scarring. Deficiency in vitamin D was shown to correlate with lowered kidney function at 3 months after transplant and increased kidney scarring at 12 months after transplant. Frank Bienaime of the Université Paris Descartes and INSERM and Assistance Publique Hopitaux de Paris. 30 patients lost their transplanted kidney. may improve transplantation outcomes.23 May 2013 News Vitamin D deficiency a concern for kidney transplant patients Laura Dobberstein idney transplant patients with vitamin D deficiency should consider taking vitamin D supplements in order to prevent a decline in kidney function. phosphorus. Mar 28.to 4-month period after receiving the transplant. and vitamin D levels were measured. thereby providing the positive calcium and phosphorus flux required for bone mineralization. The flow rate of filtered fluid through the kidney. the efficiency of the kidneys at 12 months as measured by flow rate. Other hormones associated with mineral metabolism like calcium.” said Dr. and the health of the kidneys measured through scarring and atrophy between 3 and 12 months. [J Am Soc Nephrol 2013. parathyroid hormone or fibroblast growth factor-23 were not linked to kidney health. and colleagues. The study authors encouraged future research to evaluate the use of vitamin D supplements in kidney transplant patients. Vitamin D deficiency is a common problem among those with impaired kidney function but the status of the hormone after having a kidney transplant is not well understood. “It promotes phosphate and calcium absorption by the gut and increases calcium reabsorption by the renal distal tubule. and 3 died after losing their transplanted organ. calcitriol. say French researchers. “[Our results] suggest that maintaining vitamin D concentration within the normal range would prevent renal function deterioration after renal transplantation. 28 patients died with a functioning transplant.” . Infection was the most common cause of death and was seen in 12 patients. “Vitamin D supplementation. Epub ahead of print] During the course of the study. France. a simple and inexpensive treatment. known as glomerular filtration rate (GFR). 19 of the patients were lost to follow-up.

nocturia. GlaxoSmithKline). However. However.24 May 2013 Drug Profile Dutasteride/tamsulosin: Combination therapy for BPH The true prevalence of benign prostatic hyperplasia (BPH) in male populations has been difficult to estimate due to the lack of a standardized definition. Voiding symptoms are more common while storage symptoms are more bothersome and interfere more with daily activities. may occur. in patients with BPH. the symptoms can be extremely bothersome and become more so over time as the prostate enlarges and the condition progresses. the characteristic features of BPH – abnormal proliferation of stromal and epithelial prostatic cells – become more common in men with age. The lack of a standardized definition of BPH means that it is difficult to estimate its true prevalence. a combination treatment consisting of two drugs with complementary mechanisms of action. Following a first episode of AUR. and conversely. When present. frequency. urgency and urge incontinence). hesitancy. known as acute urinary retention (AUR). painful and requires catheterization to treat it. Naomi Adam. and/or storage symptoms (eg. The following article highlights the benefits of dutasteride/ tamsulosin (Duodart®. Category 1 Accredited Education Provider (Royal Australian College of General Practitioners) Introduction Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland. AUR is a medical emergency that is often unexpected. Eventually. weak stream. . Clinically. not all men with LUTS have BPH. and 24 to 42 percent eventually go on to have prostatectomy surgery. complete blockage of the urethra. not all men with BPH suffer from LUTS. the characteristic histological features of BPH – abnormal proliferation of stromal and epithelial prostatic cells – are extremely common. patients with BPH present with lower urinary tract symptoms (LUTS) – either voiding symptoms (eg. Guidelines developed at the 6th International Consultation on New Developments in Prostate Cancer and Prostate Diseases provide an algorithm for the management of LUTS in men in the primary care setting. seen in up to 80 percent. MSc (Med). intermittency and abdominal straining). In an aging male population (≥ 80 years). the condition often recurs.

dutasteride (n=1. Clinical efficacy Recently. when in fact it is quite normal for older men to get up once per night.179:616621] The study population consisted of men aged 50 years and over with a clinical diagnosis of BPH by medical history and physical examination. But in men who do find their LUTS bothersome.25 May 2013 Drug Profile in the bladder neck.611). This provides relief from LUTS symptoms by relaxing smooth muscle . Type 2 is found in the male genitalia and the prostate. A large proportion of men who present are simply seeking reassurance. individualized medical therapy should be used to address each patient’s predominant symptoms. and key among these is the question as to whether patients find their symptoms bothersome. and kidney. The primary endpoint was the self-administered International Prostate Symptom Score [Male Lower Urinary Tract Dysfunction: Evaluation and Management. The enzyme 5-alpha reductase is present throughout the body in two forms.0 ng/mL. as well as in the liver. previous prostatic surgery or a history of AUR within 3 months before study entry were excluded from the study. and 79 percent of the population completed the 24-month follow-up visit. In men with moderate-to-severe LUTS and an enlarged prostate. prostate. or iso-enzymes: type 1 and type 2. There were comparable rates of discontinuation between the three groups. just reassurance. Its action is inhibition of sympathetic stimulation via α1-adrenoceptors. Dutasteride/tamsulosin hydrochloride Mode of action Dutasteride-tamsulosin is a combination of two drugs with complementary mechanisms of action to improve symptoms in patients with BPH. 5α-reductase inhibitors (5ARIs) reduce prostate volume and decrease urethral obstruction. Symptoms associated with obstruction due to prostatic enlargement can be relieved with α-blockers. [Duodart Prescribing Information] Tamsulosin is an α-blocker. a history or evidence of prostate cancer. This significantly reduces prostate volume in men with BPH.623) or the combination of the two agents (n=1. Dutasteride is the only licensed type 1 and type 2 dual 5ARI.610). Reports in the lay media often erroneously state that getting up to urinate during the night is a sign of prostate cancer. [J Urol 2008. Subjects were randomized to receive either tamsulosin (n=1. which is the androgen primarily responsible for hyperplasia of glandular prostatic tissue.107:1426-1431] Symptoms of overactive bladder are most often treated with antimuscarinic agents. [BJU Int 2011. Type 1 has been reported to be located predominantly in the skin. prostate and bladder detrusor. both in hair follicles and sebaceous glands. There are several pharmacological treatment options that should be used according the underling pathophysiology. 2006] The first step is a series of simple tests. the CombAT study showed that combination therapy with the α-blocker tamsulosin and the 5ARI dutasteride effectively treats LUTS due to BPH. no treatment is needed. Those with total serum prostate-specific antigen (PSA) greater than 10. For those who are not bothered by their LUTS. [J Clin Endocrinol Metab 2004. providing continual symptom improvement and reducing the risk of AUR and the need for surgery.89:2179-2184] 5ARIs block the conversion of testosterone to dihydrotestosterone (DH).

There were no instances of floppy iris syndrome or breast neoplasms. The effect of renal impairment on the pharmacokinetics of the active compounds has not been studied. The medication is contraindicated in patients with severe hepatic impairment. retrograde ejaculation. decreased semen volume.2 (± 0. A 5ARI should be offered to men with LUTS who have prostates estimated to be larger than 30 g or a PSA level greater than 1.15) and 4. Adverse reactions In the CombAT study. altered (decreased) libido. ejaculation failure. it is anticipated that no adjustment in dosage would be needed. however.4 ng/mL. The combination of an α-blocker and a 5ARI is therefore appropriate for men with bothersome moderate to severe LUTS and prostates estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ mL.9 (± 0.] (IPSS) questionnaire. Compared with either monotherapy. and the effect of mild to moderate hepatic impairment on pharmacokinetics has not been studied. the total number of drug-related adverse events (AEs) was higher in the combination therapy group. At month 24. combination therapy also significantly improved urinary flow rate and reduced prostate volume. only 5 percent or fewer men withdrew from the study due to an AE.26 May 2013 Drug Profile after the same meal each day. [The Management of Lower Urinary Tract Symptoms in Men. however. and who are considered to be at high risk of progression (eg.15) points for dutasteride and tamsulosin.3 (± 0. loss of libido and nipple pain.15) points for combination therapy versus 4. the average (± standard error) decreases in IPSS from baseline were 6. respectively. The AEs more common with combination therapy were erectile dysfunction. 2010. older men). Place within treatment guidelines Guidelines published by the National Institute for Health and Clinical Excellence (NICE) state that men with moderate to severe LUTS should be offered an α-blocker. Dosing The recommended dose of Duodart is one capsule (500 μg dutasteride /400 μg tamsulosin) taken orally approximately 30 minutes . National Clinical Guideline Centre.

Wrist sprains are common injuries to the ligaments around the wrist joint. Decreased sensibility in median nerve distribution and thenar atrophy are late signs. Tinel test of the carpal tunnel and Phalen test may be positive. radiocarpal and midcarpal. or increased distal median nerve motor latency noted on electromyography. clumsiness and weakness. There is a history of repetitive activities and overuse. the median nerve is compressed as it passes through the wrist joint. thus. pain is located on the palmar aspect of the wrist. These Managing wrist pain Dr. in patients with constant numbness. and the bases of the metacarpals distally. As the wrist can be affected by a multitude of local and general disorders.27 May 2013 In Practice literature. wrist pain is generally subdivided into traumatic or nontraumatic origin. it is often difficult to make an accurate diagnosis. Pain occurs on flexion and resisted extension. Activity modification can be tried in work-related carpal tunnel syndrome. thorough physical examination and imaging techniques (plain radiographs. palmar aspect or generalized wrist pain. motor weakness. A ganglion cyst is a swelling that usually occurs over the back of the hand or wrist. dorsal aspect. The joints around the wrist comprise of the distal radioulnar. Eugene Wong Consultant Orthopedic & Spine Surgeon Adjunct Assistant Professor Perdana University Graduate School of Medicine Serdang. In carpal tunnel syndrome. a source of pain. Malaysia he wrist joint is an area bounded by the distal radius and ulna proximally. degeneration or disease and. Patients often complain of pain around the wrist. Patients frequently wake up at night with numbness in the fingers. Each of the surrounding structures can be the site of injury. In flexor tenosynovitis. Wrist tendonitis is due to inflammation of the tendon sheath. there is pain in the dorsum of the wrist that may radiate proximally and distally. The location of wrist pain is indicative of the cause. ulnar aspect. With careful history taking. ultrasonography and bone scintigraphy). In the case of tenosynovitis of extensor tendons. Selangor. A cockup wrist splint can be used. a diagnosis of the cause of wrist pain can be made in 78 percent of cases. Surgical release of the transverse carpal ligament is performed when non-operative measures have failed. Tendonitis is a common problem that can cause wrist pain and swelling. In the T . Patients may present with swelling and pain localized to the radial aspect. numbness and tingling in the radial three digits. is aggravated with wrist motion and with resisted wrist flexion. Carpal tunnel syndrome is the most common compression neuropathy in the upper extremity. Treatment of wrist pain caused by tendonitis usually does not require surgery.

De Quervain tenosynovitis is due to inflammation of the first dorsal compartment of the extensor tendons. Radiographs of patients with inflammatory arthritis show narrowing of joint space. Carpal instability 5. Kienbock’s disease 4. 1st CMC arthritis 3. Ulnar impaction syndrome 7. Ganglion cysts are the most common mass on the dorsal surface of the wrist. subchondral sclerosis and osteophytes. A wrist prosthetic implant is used to maintain pain-free range of motion. Undisplaced fractures may be casted and a screw fixation done for displaced fractures. 1. bone erosion and deformity. Most arise from the scapholunate ligament.28 May 2013 In Practice are benign. Swelling. The arthritic carpal bones can be excised. intercarpal and carpometacarpal (CMC) joints present with pain in the wrist. There is a history of repetitive wrist activities. There is tenderness over the anatomic snuffbox. De Quervain tenosynovitis 8. The Finkelstein test (with thumb flexed into palm. Patients with inflammatory arthritis and osteoarthritis involving the radiocarpal. fluid-filled capsules. Radiographs of patients with osteoarthritis show narrowing of the joint space. Ganglion cyst . Surgery involves removing the cyst as well as part of the involved joint capsule or tendon sheath. Joint fusion is done in cases of severe pain. An anesthetic injection around the tendon sheath can be given. Septic arthritic wrist 10. Arthritis is a problem that can cause wrist pain and difficulty performing daily activities. If the ganglion causes a pain or severely limits activities. osteopenia. there is a small chance the ganglion will return. Scaphoid fracture is most often due to a fall on an outstretched arm. Pseudogout 9. the fluid may be drained. Some patients may require surgical release of the first dorsal compartment. Patients with osteoarthritis may have a history of trauma. pain is reproduced by ulnar deviation of the wrist) is positive. TFCC tear 6. Even after excision. Scaphoid fracture 2. stiffness and decreased range of motion are present.

X-rays of the wrist are usually a first step and will help determine if more tests are needed. sarcoid. erythrocyte sedimentation rate (ESR) and C-reactive protein are signs of infection. swelling. .29 May 2013 In Practice Radial wrist pain: • • • • De Quervain tenosynovitis Scaphoid fracture or non-union Thumb CMC arthritis Radiocarpal arthritis In cases of distal radioulnar joint instability. diabetes. Immunocompromised patients or those with a history of intravenous drug use are at higher risk of wrist infection than the general population. multiple myeloma) •  Metabolic conditions (eg. pregnancy. physical examination and the use of several diagnostic tests. psoriasis. with a carpal tunnel view for fracture of the hook of the hamate. decreased range of motion (ROM) and other cardinal signs of infection may be present. lateral and oblique radiographs are obtained to look for fracture. Pain at the flexor carpi ulnar is usually detected on resisted wrist flexion and ulnar deviation. Increased pain with ROM is characteristic. Finding the cause of wrist pain begins with a detailed history. The treatment of wrist pain depends entirely on the cause of the problem. An arthroscopic repair can be done. especially with pronation and supination. hypocalcemia. Paget’s disease. • Triangular fibrocartilage complex • Distal radioulnar joint subluxation • Carpal instability • Scapholunate dissociation • De Quervain’s tenosynovitis • Intersection syndrome • Neoplasm or ganglion Neurologic causes: • • • • • Distal posterior interosseous nerve syndrome Injury of median nerve (carpal tunnel syndrome) Injury of radial nerve Injury of ulnar nerve (Guyon’s canal) Thoracic outlet compression syndrome Systemic causes: • Amyloidosis • Granulomatous disease (eg. Mechanical causes: • Fracture • Non-union of scaphoid or hook of the hamate •  Avascular necrosis of the scaphoid (Preiser’s disease) or lunate (Kienböck’s disease). An ultrasound scan can be used to diagnose tendon tears around the wrist. Plain anteroposterior. rheumatoid arthritis. pain is located at the distal radioulnar joint. Table 2: Etiology of wrist pain. leukemia. Blood tests are done to look for infection or arthritis. A triangular fibrocartilage complex (TFCC) tear presents with ulnar-sided wrist pain. Pain. Magnetic resonance imaging (MRI) is commonly used to evaluate the wrist because it can show abnormal areas of the soft tissues. • Osteomyelitis • Peripheral neuropathy •  Reflex sympathetic dystrophy (complex regional pain syndrome). hyperparathyroidism. gout. scleroderma. Elevated leukocyte count. acromegaly. erythema. MRI may be useful in the diagnosis of TFCC tear and wrist infection. •  Rheumatologic disorders (eg. Dorsal wrist pain: • Tenosynovitis of extensor tendons • Ganglion cyst • Extensor carpi ulnaris tendinitis Ulnar wrist pain: • • • • Distal radioulnar joint instability Flexor carpi ulnaris tendinitis Fracture of the hook of the hamate TFCC tear Palmar wrist pain: • Flexor tenosynovitis • Carpal tunnel syndrome (CTS) • Palmar ganglion General wrist pain: • Arthritis • Infection Table 1: Regional distribution of wrist pain. Pain is experienced with axial load while rotating the ulnar-deviated wrist. pseudogout). tuberculosis) • Hematologic disease (eg. often with clicking. systemic lupus erythematosus). A scaphoid view is used to assess scaphoid fracture. hypothyroidism.

• Wrist support: Support braces can help patients who have either had a recent wrist sprain injury or those who tend to injure their wrists easily.30 May 2013 In Practice • Anti-inflammatory medication: Nonsteroidal anti-inflammatory drugs (NSAIDs) are some of the most commonly prescribed medications. • Ice and heat application: Ice packs and heat pads are among the most commonly used treatments for wrist pain. Adjusting activities so as not to irritate the joint can help prevent worsening of wrist pain. Arthroscopic surgery is a treatment option available for some causes of wrist pain such as TFCC tear and arthritis. wrist replacement or fusion may be required. and allow the acute inflammation to subside. clinical examination and appropriate imaging will identify the cause of wrist pain. These braces act as a gentle support for wrist movements. . They will not prevent severe injuries. however. A detailed history taking. Some wrist conditions require arthroscopy for diagnosis or treatment. • Cortisone injections: Cortisone is used to treat inflammation which is a common problem in patients with wrist pain. • Rest and activity modification: The first treatment for many common conditions that cause wrist pain is to rest the joint. In cases of severe pain arising from arthritis. It is important. especially for patients with wrist pain caused by arthritis and tendonitis. to use caution when resting the joint because prolonged immobilization can cause a stiff joint. Diagnostic injections are sometimes needed. but may help the patient perform simple activities while rehabilitating from a wrist sprain.

it can be difficult to negotiate the Tube. horrifying and rewarding – often within the same journey. Its history and culture is rich. Patriot Games. Using the Tube With its bustling 3. It has inspired poetry. From that single line of 6 kilometers. Reviled occasionally.000 passengers on its first day in January 1863. it is just a fact of life. The Metropolitan Railway hauled 38.5 million passengers each day. To visitors. Ever wondered which station you keep seeing in London film sets? Good odds that it’s the disused Aldwych station on the Piccadilly line. it can be fascinating. the locomotives were steam powered and the wooden carriages were illuminated by gas lamps. featured in films and been the subject of countless documentaries and magazine articles. the world’s first underground railway opened. Ghosts abound. One hundred and fifty years ago. Some of these .31 May 2013 After Hours Getting Around on the Joseph Hoye here may be bigger and there may be busier. A broad gauge railway. traveling the 6 kilometers between Paddington and Farringdon. V For Vendetta and Atonement are amongst the many films to use this station. there now runs 402 kilometers of electrified track with trains servicing 270 stations across 26 London boroughs and into neighboring counties. it is the pulsing artery of a sprawling city that depends on mass transit to stay alive. London Underground T Jump forward to today. It may seem like chaos but the London Underground does have an etiquette that helps keep the system moving. There’s even a book chronicling the mice of the Underground. civilians took shelter during bombing raids. For most Londoners. but no one can deny the London Underground its place in history as the world’s first underground rail system. US talk-show host Jerry Springer was born in the Underground. praised sporadically.

users must still touch cards to the terminals. barrier arms at some stations may be raised. Most of London’s key sites of interest are within Transport Zones 1 and 2 and it would not be inconceivable to visit Buckingham Palace. On Sundays. London Eye. Of course the whole point of the Underground is to move people quickly around a large city that was never designed for railways. it pays to check the Tube map to see which stations have the best access. The fold-up illustration handily fits inside a wallet or pocket. the Tower of London and Hyde Park in one day if travelling on the Tube. remain alert to people trying to walk at a faster rate than you. the Shard. And if you do have to travel at these times. The stations are arranged to fit on a small sheet of paper. Pick up a copy from any Underground station. Let them pass. Waterloo Station: check. •  Stand aside to allow passengers off carriages before you enter. stand on the right side and remain in single file. consider an Oyster card. There are plenty of apps that do the job but the modern version of Harry Beck’s 1933 design classic is a life saver. If there’s one thing every visitor to London needs. Buying tickets for the Tube is very simple. seemingly for no reason. •  Food and drink are permissible in stations and on trains but alcohol and smoking are not. Westminster. The Tube journey from Heathrow to the City may be time consuming but is worth considering if guidelines are written on the walls throughout the maze of pedestrian tunnels but generally they’re just common sense. If you’re going to be traveling extensively. day passes. never use it to work out the distance needed to get to your destination. Heathrow: check. If in doubt. St Pancras International (Eurostar): check.32 May 2013 After Hours pram-friendly. the Underground gets very busy at certain times of the day. move into the center of the carriage you’re traveling on. thus. Options are for single fares. London is spoiled for choice when it comes to long distance travel options and each is easily reached via the Underground. It’s not uncommon to have a set of three or four stairs to negotiate along walkways. bus trips are included in the weekly/ monthly options. let alone motorways. •  Oyster Card users must touch in and out or risk a fine. walk on the left. two adjacent stations may be anywhere from 500 meters to 5 kilometers away from each other. weekly or monthly cards. London City Airport: check. keep to the left side of station walkways. it’s the free Tube map. If at all possible. And not all stations have step-free access onto the carriages. is color-coded to reduce confusion and clearly shows the junctions where passengers can change lines. The London Underground is an old rail system. be prepared to have two or three trains pass by before you get on. Not only does it automatically discount fares. While many stations have lifts or escalators. That said. Most stations have a series of automated booths that take cash or card. some are neither wheelchair nor . • I  f possible. •  If you are travelling in a group. Like any transport option. •  On escalators. • U  nless signage declares otherwise. avoid traveling on weekdays before 9:30am or between 5pm to 6:30pm.

Do not discount London’s famous black cabs as a way to move around the city but do be aware that longer trips can be somewhat pricey and traffic holdups can last several hours. the River Thames is also a great option for anyone wanting to move quickly or see many of London’s famous landmarks. the Heathrow Express is out of action or the motorways are snarled up. London has much to offer. choose the Tube. London isn’t just the inner city. Theaters. Used to get from A to B or enjoyed in its own right. London also has a very good overland rail service as well as an excellent bus service . Sometimes. Horse Guards. Downing Street. football. Wimbledon and Europe’s largest shopping centre – Westfield Stratford – are all directly accessible via the Tube. Harrow. Finally. Wandering a 500 meter radius around Trafalgar Square nets the National Gallery. whether you live there or are just passing through for a few days. Kew Gardens. HMS Belfast. the Tube is London’s underground superstar. There are occasions when the Underground is not a travel option. Covent Garden and the Thames. restaurants.some of the bus routes operate a 24-hour service. Shanks pony is the best way to get around London but for the rest of the time.33 May 2013 After Hours moored on the river. It is as much a part of the city as the Tower of London or Tate Britain and is rightly celebrating 150 years of service. Leicester Square. museums: all are world class and all owe a debt to the Underground. Piccadilly Circus. is particularly daunting when seen from the deck of a ferry. And it is easy to walk the streets of London. originally a light cruiser for the Royal Navy and now a museum ship permanently .

I chose not to attempt the next and steepest portion of the ride as the path climbs upwards in order to . had to walk up. the northern edge of The Presidio park. less than toned through the quadriceps. and mapped out what would be a 13-kilometer ride hugging the San Francisco Bay. the bridge has always been open to pedestrian traffic. across the bridge and down to Sausalito in Marin County where I could catch a ferry back to the city. the center of San Francisco’s historical fishing district and a popular tourist spot. Beyond that first very short hill was Fort Mason Green and further.34 May 2013 After Hours Biking the Golden Gate Bridge Radha Chitale T he Golden Gate Bridge cuts a russet swoop across the San Francisco skyline. The first incline came almost immediately after I set off from Hyde Street. Completed in 1937 to connect the main part of the city to its rapidly expanding northern counties. Pushing my bicycle up the hill did give me time to admire a clear view of the bay and Alcatraz Island. I thought the best way to experience this icon of modern architecture up close would be a leisurely cycle. snapping too many photos of sailboats cutting through the bay. Graced with sunny weather on a recent trip to San Francisco. The route to the bridge is mostly flat but there are several steep hills that I. The staff at Blazing Saddles. once the site of the famous high-security prison. outfitted me with a bike. The quiet. a bicycle rental company. green ride required no great effort. Having rested sufficiently. so I took my time. The whole ride would take about 2-and-a-half hours. Crissy Field. lock and water. I started at Fisherman’s Wharf. helmet.

000 metric tons. Safety signs warn about high winds while crossing. The whole structure looks delicate from afar but the main cables are almost 1 meter in diameter and the total weight of the bridge is over 800. 4 hours after I began. My discomfort was more than compensated by the expanse of the Pacific Ocean and the gentle green hills of Marin County. but small outcroppings of footpath allow a place to rest or take pictures clear of passing cyclists and pedestrians. popular in the 1930s. saying it was an easy 20-minute ride. I will be more wary of pro-looking cyclists in bright yellow biking shorts who tell me a hill is not big because once again I found myself pushing my bicycle uphill. vertical ribbing and diminishing towers are hallmarks of art deco style. but while the winds did not interfere with my balance. I caught the last ferry back to the Port of San Francisco. as if they soared beyond illumination. go from sea level to the base of the bridge 67 meters above. Some care is necessary when riding. a span suspension design in which the roadway hangs off vertical suspenders attached to cables strung between 227-meter high towers. as there are several blind turns as the footpath curves around the main towers. I certainly could have used some gloves and an extra sweater under my down vest. A fellow cyclist advised me to continue on and catch the ferry. However. Out of the sun it was chilly and I debated continuing on to Sausalito. The Golden Gate Bridge was only the longest suspension bridge in the world until 1964. . I made my way under the bridge to the west side where cyclists could get on the footpath. The simple railings. or head back the way I came. chosen to complement the warm colors of the surrounding land masses and contrast with the cool blues of sea and sky. Did You Know? The Golden Gate Bridge has always been painted International Orange. The bridge towers have fewer lights towards the top to appear more majestic at night. The gradual incline I felt as I pedaled started to give as soon as I passed the halfway point and I quickly reached the far side of the bridge. I hopped on my bike again and cycled up the Embarcadero back to Fisherman’s Wharf to return it. In the future. which also makes it more visible to passing ships through the Bay fog. It has appeared prominently in a number of films including Superman (1978). The distinctive orange bridge loomed large as soon as I crested the hill. the subsequent coast into picturesque Sausalito was enjoyable.35 May 2013 After Hours With just enough time for a restorative coffee. an unknown route. Interview with a Vampire (1994) and The Rock (1996). The bridge can expand or contract by up to 16 feet when the temperature changes. and instead enjoyed watching more able cyclists chug past me. but it is still the most photographed bridge in the world.

I know who you are!” “She can forgive Lance Armstrong but she can’t forgive me!” “Just make sure you don’t take these sleeping pills and a laxative on the same night!” “Whatever it is going around. if you loosen your belt a little.36 May 2013 Humor “I think. but let’s be totally fair. you won’t be experiencing those terrible chest pains!” “I know you must be in a lot of pain. This is your night to do the dishes!” “Don’t try to hide under those masks. you have it!” .

co.com Website: www.asco. Korea Info: WCTI Secretariat Tel: (82) 2 3452 7245/(82) 2 3471 8555 Fax: (82) 2 521 8683 Email: wcti2013@insession. England Info: ECO2013 Secretariat Tel: (44) 20 8973 2506 Email: enquiries@easo.org Website: www.easo.org. Malaysia Info: Asia Diabetes Foundation Tel: (852) 2637 6624 Fax: (852) 2647 6624 Email: enquiry@adf. 4025 3700 Website: www.adf.aua2013.iddforum.eapc-2013.de Website: www. Australia Info: MDS Congress Staff Tel: (1) 414 276 2145 Fax: (1) 414 276 3349 Email: congress@movementdisorders.com 20th European Congress on Obesity 12/5/2013 to 15/5/2013 Location: Liverpool.hk/dpp2013 3rd World Congress of Thoracic Imaging 8/6/2013 to 11/6/2013 Location: Seoul. US Info: AUA Tel: (1) 410 689 3700 Fax: (1) 410 689 3800 Email: customerservice@AUAnet.org/liverpool-eco-2013 Diabetes Preventing the Preventables Forum 24/5/2013 to 26/5/2013 Location: Kuala Lumpur.org International Digestive Disease Forum 2013 8/6/2013 to 9/6/2013 Location: Hong Kong Info: UBM Medica Pacific Limited Tel: (852) 2155 8557 Fax: (852) 2559 6910 Email: info@iddforum.hk Website: www.wcn2013.kr Website: www.org JUNE 23rd Conference of the Asian Pacific Association for the Study of the Liver 6/6/2013 to 9/6/2013 Location: Singapore Info: APASL Secretariat Email: apaslconference@kenes. Czech Republic Info: European Association for Palliative Care Tel: (49) 89 548234 62 Fax: (49) 89 54823443 Email: eapc2013@interplan.org.com Website: www.org 46th Annual Meeting of the European Society for Paediatric Gastroenterology.org 9th Asian Society for Paediatric Research Congress 9/5/2013 to 12/5/2013 Location: Kuching. Hepatology and Nutrition 8/5/2013 to 11/5/2013 Location: London.mdscongress2013.com Website: www.org 12th Congress of the European Association for Palliative Care 30/5/2013 to 2/6/2013 Location: Prague.apaslconference. Illinois.org American Urology Association (AUA) Annual Meeting 4/5/2013 to 8/5/2013 Location: San Diego.org 17th International Congress of Parkinson’s Disease and Movement Disorders 16/6/2013 to 20/6/2013 Location: Sydney.37 May May 2013 Calendar American Society of Clinical Oncology Annual Meeting 31/5/2013 to 4/6/2013 Location: Chicago.org Website: www. US Info: ASCO Customer Care Tel: (1) 888 282 2552 or (1) 571 483 1300 Website: http://chicago2013.org Website: www. California. 4025 4700. Malaysia Info: ASPR-PSM 2013 Congress Secretariat Tel: (603) 4023 4700.wcti2013.espghan2013. England Info: ESPGHAN Organizers Tel: (44) 845 1800 360 Email: ESP2013-Reg@mci-group.org World Congress of Nephrology 31/5/2013 to 4/6/2013 Location: Hong Kong Info: ISN World Congress of Nephrology 2013 Tel: (852) 2559 9973 Fax: (852) 2547 9528 Email: registration@wcn2013.org .org Website: www.aspr-psm2013.

Malaysia Info: AFSM Organizers Email: 13afsm@gmail. Download the digital edition today at www.adc2013.org upcoming 9th Asian Dermatological Congress 10/7/2013 to 13/7/2013 Location: Hong Kong Info: ADC 2013 Secretariat Tel: (852) 3151 8900 Email: adc2013@swiretravel. Illinois.13afsm.VeniceArrhythmias 2013 27/10/2013 to 29/10/2013 Location: Venice.jpog.venicearrhythmias.org READ JPOG ANYTIME.com Website: www.org Website: www.org 13th International Workshop on Cardiac Arrhythmias .com Website: www.com .diabetes. Italy Info: VeniceArrhythmias 2013 Organizing Secretariat Tel: (39) 0541 305830 Fax: (39) 0541 305842 Email: info@venicearrhythmias.com American Diabetes Association 73rd Scientific Sessions 21/6/213 to 25/6/2013 Location: Chicago.com Website: http://scientificsessions. US Info: ADA Registration Customer Care Center Tel: (1) 415 268 2086 Email: ADAReg@cmrus.38 May 2013 Calendar 13th Asian Federation of Sports Medicine Congress 25/9/2013 to 28/9/2013 Location: Kuala Lumpur. ANYWHERE.

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