15-31 March 2012

www.medicaltribune.com

Many women still shun contraceptives

MALAYSIA FOCUS
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Coronary calcium score may help risk assessment in asymptomatic individuals

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Many women still shun contraceptives

Malvinderjit Kaur Dhillon he Ministry of Health (MOH) is facing a setback in achieving the Millennium Development Goal (MDG) 5 as the Malaysian Population and Family Survey shows a stagnant contraceptive use prevalence rate, says an expert. The survey, carried out by the National Population and Family Development Board at 10-year intervals beginning 1974, showed the rate was 52 percent in 1984 and almost stagnant at 51.9 percent in 2004. [Economic Planning Unit (EPU) Prime Ministers Department Malaysia. www.epu.gov.my/c/document_library/ get_file?uuid=c1eb31df-0355-47c39892-f57c795c504b&groupId=34492 Accessed on 28 February] According to the United Nations Development Programme [UNDP] goal, we have yet to achieve MDG 5 in terms of maternal mortality ratio [MMR] and reproductive health services. For example, looking at MDG target 5a, we have to reduce the MMR by 75 percent by 2015. Currently, our MMR is 28 per 100,000 births, and if we look at the Ministry of Healths Confidential Enquiries into Maternal Deaths [CEMD], the rate is higher. Nevertheless, the MOH is confident it is on track and hopes to reach the target MMR of 11 per 100,000 births, said Dato Aminah Abdul Rahman, Director-General of the National Population and Family Development Board (LPPKN). [UNDP. www.undp.org. my/uploads/mdg5.pdf, EPU. www. e p u . g o v. my /c / d o c u m e n t _ l i b r a r y /

A large number of women still do not practise birth control due to various reasons.

get_file?uuid=c1eb31df-0355-47c39892-f57c795c504b&groupId=34492 Accessed on 28 February] There is also an unmet need for family planning. The rate of married women who do not plan on having any more children but are not using any form of contraceptives is high. During the last decade, the unmet need has increased to 24.5 percent from less than 20 percent previously. Almost 27 percent of women do not practise family planning as they are afraid of the side effects. There is definitely room for education in this area.

15-31 March 2012

Some 12.6 percent do not practise family planning due to their husbands objection, said Aminah, who was speaking at the launch of the Maternal and Infant Care (Mi-CARE) program. [UNDP. www.undp. org.my/uploads/mdg5.pdf Accessed on 28 February] Aminah urged everyone involved in the Mi-CARE program, as well as agencies providing access to reproductive health, to take this as a challenge and to reach out to those who are marginalized or do not have access to family planning services. Mi-CARE was established by the Obstetrics and Gynaecology Society of Malaysia (OGSM), Nutrition Society of Malaysia (NSM), the National Midwives Society of Malaysia (NMSM) and the Malaysian Paediatric Association (MPA). Mi-CARE aims to promote a more

holistic approach to pregnancy, birth and infant care. The program involves training workshops for midwives, nurses and nurse aides serving in maternity centers, and private and government obstetrics and gynecology and pediatric clinics. The content of the program was developed and will be delivered by a team of experts in obstetrics and gynecology, diet and nutrition, physiotherapy and pediatrics. Mi-CARE also aims to reach out to mothers via the Mi-CARE Telephone Advisory Centre*, which is manned by either a nutritionist or a trained nurse.
Doctors wishing to enrol their nurses in the Mi-CARE program can call the Secretariat at (03) 5621 1408. *Mi-CARE Telephone Advisory Centre: 1 800 88 9033

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Forum

Turning the tide on chronic diseases in Asia: The need for innovative solutions
Excerpted from a presentation by Professor Harvey Fineberg, president of the Institute of Medicine and former Dean of the Harvard School of Public Health, Cambridge, Massachusetts, US, during the National University of Singapore Initiative to Improve Health in Asia (NIHA) forum held in Singapore recently.
he two elements in the title, chronic diseases and Asia, are each heterogeneous and complicated. The countries of Asia range from a population of 400,000 in Brunei to more than 1 billion each in India and China. The range of economic development in the region is equally disparate. The countries also vary in their stage of epidemiologic transition, with many simultaneously facing a high burden of infectious diseases and chronic diseases. Although a single solution is unlikely to suit every country in the region, certain lessons and principles can apply across all. The terminology of non-communicable diseases is problematic. Many chronic diseases have infectious origins, including liver cancer (hepatitis B and C), gastric cancer (H. pylori) cervical and oral cancers (human papillomavirus). Similarly, a number of acute illnesses are not infectious. The separation between acute and chronic, communicable and non-communicable is, thus, imperfect. What unites our concern about these diseases is that they persist over time, are prevalent in all parts of the world, and are rising in their incidence and significance as part

of the total disease burden. Cancers, heart disease, lung disease, diabetes, and neurological and mental problems fall into this category. We tend to overlook this last group, but neurodegenerative diseases and mental illnesses such as depression will soon constitute the leading cause of the global disease burden. We need to apply our creative talent in new, innovative ways to come up with novel solutions. One useful perspective is to consider diseases according to the stage of life and stage of disease evolution in individuals and populations eg, problems of the young, the middle-aged and the elderly. Another useful perspective is to design interventions according to the stage of disease development, including pre-disease, disposition to disease, early disease, full blown disease and sequelae of disease. The activities of the Global Taskforce on Expanded Access to Cancer Care and Control in Developing Countries, which focus on low- and middle-income countries and organizes its thinking according to detection, diagnosis, prevention, treatment, survivorship and palliation of cancer, is a good example of this type of approach.

15-31 March 2012

Forum
worked in a way that would convince a skeptic? If we can design strategies that fit these criteria that will have impact, are adoptable and affordable, implementable, sustainable and amenable to evaluation then we will have made significant progress. At least 10 modes of action can be employed in the design of intervention strategies: (1) the legal foundation (such as tax policy or environmental laws) needed to mount the intervention; (2) regulatory policy and infrastructure for foods, tobacco, drugs and devices; (3) research (basic, translational, applied and evaluative) to devise new tools and assess what has worked; (4) monitoring, surveillance and measurement to get a more accurate picture of disease burden over time; (5) education of the spectrum of health professionals, including interprofessional training; (6) advocacy and public communication, including information technology and the use of social and entertainment media; (7) organization and preparedness of the health system to provide needed services; (8) capacity for implementation, including authority and decision control systems; (9) adequate financing mechanisms; and (10) alignment of action across ministries, universities and other institutions, public health and medicine, and public and private sectors. These mutually inclusive modalities represent great opportunities individually and in combination. Successful strategic combinations that fulfill the six criteria hold the prospect of great progress against chronic diseases in Asia and in other parts of the world.

Framing strategies according to risk factors represents another useful strategic framework beyond the classification by population and the stage of development of disease. Tobacco, for example, leads to a number of chronic diseases including heart disease, lung disease and cancer. Diet and obesity similarly contribute to a number of diseases, including diabetes. Reducing a single source of risk can often reduce the incidence of multiple diseases. Six criteria can guide the choice of interventions against chronic diseases: Impact: Is the intervention effective, aimed at an important problem and scalable to apply to the totality of the problem? Adoptability: Is the intervention politically and culturally acceptable? This depends on the specific design of the intervention and on the political, social and cultural context of each jurisdiction. Affordability: Is the intervention economically justified, cost-effective and affordable? The diversity of economic situations in different countries may dictate different answers for the same intervention. Implementability: Is the strategy practical and implementable? Can you manage all the steps necessary to go from an idea to tangible change based on this strategy? Sustainability: Some interventions may be completed in a single step, such as immunization against HPV or hepatitis B, while others, such as diet, demand daily attention. Evaluation: Can you demonstrate whether the intervention has

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Medical Briefs

Migraine in mother, colic in baby

abies whose mothers have a history of migraine are more likely to have colic, a US study has shown. The study, conducted by neurologists at the University of California, San Francisco (UCSF), found that babies whose mothers had a history of migraine were two-and-a-half times more likely to have colic than infants whose mothers did not have a history of migraine. Overall, 29 percent of infants whose mothers had migraine had colic compared to 11 percent of babies whose mothers did not have migraine. For the study, researchers analyzed information on 154 mothers and their babies. Colic was reported by parents based on questions developed by study researchers using standard criteria for colic. The study findings will be presented at the American Academy of Neurologys 64th

Annual Meeting in New Orleans in April. Since migraine is a highly genetic disorder, our study suggests that infant colic may be an early sign that a child may be predisposed toward migraine headache later in life, said study author Dr. Amy Gelfand, a child neurologist with the Headache Center at the UCSF, and a member of the American Academy of Neurology.

Migraine ups depression risk in women

igraine may lead to depression in some women, shows a US study. Women with a history of migraine were found to be about 40 percent more likely to develop depression than those without a history of migraine, according to the study. Researchers classified 36,154 women without depression who were enrolled in the Womens Health Study and had provided information about migraine. They were classified as either having active migraine with or without aura, past history of migraine (but not within the last

year) or no history of migraine. A total of 6,456 women had current or past migraine. During an average 14 years of follow-up, 3,971 of the women developed depression. The study findings will be presented at the American Academy of Neurologys 64th Annual Meeting in New Orleans in April. We hope our findings will encourage doctors to speak to their migraine patients about the risk of depression and potential ways to prevent depression, said Dr. Tobias Kurth, of Brigham and Womens Hospital in Boston.

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10 15-31 March 2012 Malaysia Focus Coronary calcium score may help risk assessment in asymptomatic individuals
Leonard Yap

oronary calcium scores can be used in predicting the risk of coronary artery disease (CAD) in individuals with low-tointermediate risk, says a cardiologist. Coronary calcium scores are usually considered to be the least accurate of noninvasive heart diagnostic tools, but they still have their place in cardiology, said Dr. Wong Teck Wee, a consultant cardiologist. This test is very easy, quick and very low in radiation [exposure]. The disadvantage of coronary calcium is that it does not look at stenosis, but if you have a calcium score of 0, the chance of having significant coronary stenosis is very unlikely. The negative predictive value is very high, 97 percent, and the higher the calcium score, the more likely it is to have significant stenosis, he said. [J Am Coll Cardiol 2010;56:2182-99] With this [information from the calcium score] you can change the therapeutic goal [of your patient], you can get your patient to comply with lowering their cholesterol, controlling blood pressure and keeping their blood sugar under control.

Calcium scores are a good indication of the state of health of a patients coronary arteries.

calcium scores are also known as cardiac calcium scans. In normal circumstances, coronary arteries do not contain calcium. Its presence is a sign of CAD. [www.nhlbi. nih.gov/health/health-topics/topics/ cscan/ Accessed on 21 February] The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) recommended coronary artery calcium (CAC) scores in their 2010

... the higher the calcium score, the more likely it is to have significant stenosis ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults for the following conditions: Measurement of CAC is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk

Coronary calcium scores utilize computed tomography (CT) scan to check for the build-up of calcium plaque on the walls of the coronary arteries. This test is used to check for heart disease at an early stage and to determine its severity. Coronary

11 15-31 March 2012 Malaysia Focus

(10 percent to 20 percent 10-year risk). (Level of Evidence: B) Measurement of CAC may be reasonable for cardiovascular risk assessment in persons at low-to-intermediate risk (6 percent to 10 percent 10-year risk). (Level of Evidence: B) [J Am Coll Cardiol 2010;56:2182-99] There is evidence that CAC scores are a reasonable surrogate for coronary atherosclerosis burden in adults. [Circulation 1995;15(92):2157-62, Am J Cardiol 1994;73:1169-73] A number of studies have demonstrated the independent prognostic value of assessing CAC to predict future coronary events in asymptomatic individuals [Circulation 2000;101:850-5, Circulation 1996;93:19513, J Am Coll Cardiol 2000;36:1253-60] Wong was speaking at the Weekend Seminar in Cardiology for GPs 2012 held in Kuala Lumpur recently.

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12 15-31 March 2012 Malaysia Focus Rotavirus: Vaccines the best preventive measure
Malvinderjit Kaur Dhillon nterventional measures, including improving sanitation and food hygiene, regular disinfection of hands and toys, and breastfeeding, alone are not enough in preventing rotavirus infection, says an expert. The most effective way to reduce severe rotavirus-associated diarrhea and mortality rates is through the use of the oral rotavirus vaccine, said Dr. Chai Pei Fan, a consultant pediatrician, at a media briefing. WHOs Strategic Advisory Group of Experts (SAGE) emphasizes the use of the rotavirus vaccine as part of a diseasecontrol strategy and has recommended that it be included in national immunization programs. (WHO. www.who.int/ mediacentre/news/releases/2009/rotavirus_vaccines_20090605/en/index.html Accessed on 24 February) There are currently two vaccines available in the market and the vaccine can be administered as early as 6 weeks old. The doses should be completed between 6 and 8 months, said Dr. Chai. There is no specific antiviral treatment for rotavirus. Most clinicians would probably prescribe the usual diarrhea medication, kaolin and pectin, which arent very effective in children with gastroenteritis. More recently, the use of diosmectite has become more common. It reduces the duration of diarrhea, amount of stool and hospitalization, but it will not stop a rotavirus infection immediately. Chai stressed that the mainstay of treating patients infected with rotavirus is to prevent dehydration, so oral rehydration

therapy is highly recommended. However, isotonic drinks do not provide adequate electrolytes and are more suited for sportsmen. In severe cases, especially in patients suffering from vomiting, rehydration and maintenance fluid should be given intravenously. [Pediatr Infect Dis J 2003;52:1-16] Children can be infected with the rotavirus several times during their lives, and the first infection is usually the worst. [Australian Government Department of Health and Ageing. www.immunise.health. gov.au/internet/immunies/publishing. nsf/Content/immunise-rotavirus Accessed on 24 February] Common symptoms of a rotavirus infection include severe diarrhea, frequent vomiting episodes lasting more than 3 hours, a temperature of 39.4oC or higher, and lethargy and irritability. Ninety percent of infected patients are usually clinically dehydrated on admission and 80 percent require IV fluids. [Malaysian J Med 2007;62:189-94] Severe dehydration may lead to death if left untreated. Therefore, it is important for clinicians to be able to recognize symptoms of severe dehydration. (Table 1)
Table 1: Symptoms of a severely dehydrated child. Weakness, tiredness or unconscious state. Dry mouth and tongue. No tears when crying. Sunken eyes. Reduced skin turgor. Cold hands and feet. Infrequent wet diapers. MWWR 2003;52(RR-16):1-16

14 15-31 March 2012 Malaysia Focus

Surveillance of visits to outpatient clinics for acute gastroenteritis (AGE) between 1998 and 2000 showed a mortality rate of 2.5 deaths per 100,000 children. [J Infect Dis 2005;192:S80-S86] Research conducted at University Malaya Medical Centre over the past 15 years and a 1-year nationwide survey found rotavirus to be the main cause of severe AGE in Malaysian children. [Med J Malaysia 2007;62:189-193]

An easier method to measure protein intake

Leonard Yap iguring out whether your renal-impaired or malnourished patient is getting the right amount of protein in their diets can be complicated and time consuming, says an expert. Conventional methods to estimate a patients protein intake are too complex and time consuming to be used in clinical practice, said Lim Su-Lin, senior assistant director and chief dietitian, dietetics department, National University Hospital, Singapore. Thus, the need for a system to quickly estimate a patients protein intake and make the necessary protein recommendations in one sitting, she said. The expedited 10 g protein counter (EP10) was developed to speed up the quantification of a patients dietary protein intake and recommendation for dietary adjustment in the clinical setting. EP-10 dispenses with the need to use separate protein calculations for different food groups to quantify dietary protein intake. This is done by making the following assumption: For every 10 g of protein consumed, 70 percent or 7 g of it is considered a high biological value protein (proteinrich). The remaining 3 g is considered to be protein of low biological value. By making this assumption, foods high in starches can be removed from consideration. [J Ren

Nutr 2012 Jan 6 Epub ahead of print] The EP-10 is a unified system that allows easier quantification of protein by ignoring non-protein-rich foods and assigning EP-10 points to protein-rich food only. EP-10 is a relatively easy way to quantify protein intake and can be taught to doctors and patients, Lim added. Patients, in particular, will benefit as they can estimate their own protein intake and make the necessary dietary adjustments. There has been no published literature on a quick and suitable method of dietary protein intake estimation for clinical practice. [Clin Nutr 2005:24:768-74, Am J Clin Nutr 1985:42;554-9] Currently, the most commonly used method is the 7 g Protein Exchange List developed by the American Dietetic Association in 1950 for use in patients with diabetes mellitus. [Diabetes Educ 1991;17:474-82, J Am Diet Assoc 2008;108:883-8] Lim was speaking at a nutrition workshop held in Kuala Lumpur recently.

15 15-31 March 2012 Malaysia Focus Extra-gastrointestinal manifestations of H. pylori

Malvinderjit Kaur Dhillon elicobacter pylori has been linked to several conditions and this has been labelled as the extra-gastrointestinal manifestation of the bacteria, but only two conditions have the most convincing evidence thus far: idiopathic thrombocytopenia purpura (ITP) and unexplained iron deficiency anemia (IDA). To prove a causal relationship, firstly you really have to have a close relationship between the two. There has to be a biologically plausible mechanism, H. pylori infection should precede the development of the disease and, lastly, eradication of H. pylori should result in an improvement in the condition or cure the disease, said Dr. Tan Huck Joo, a consultant gastroenterologist.

plausible mechanism between H. pylori and ITP. Eradication of H. pylori is useful in some patients. The detection and eradication of H. pylori is worthwhile. There is obviously a need for larger trials and longer term follow-up, said Tan. A possible link between H. pylori and IDA was reported by several studies, with the first case report published in the early 1990s. [J Pediatr Gastroenterol Nutr 1993;17:225-7] The suggested mechanism involves iron absorption interference due to an alteration in duodenal mucosa as iron is mainly absorbed in the upper duodenum. Studies show that iron absorption tests are normalized after eradication of H. pylori. [Dig Liver Dis 2004;36(7):455-60] The role of H. pylori in coronary artery disease and stroke has also been studied.

Several controlled prevalence studies suggest a higher than expected prevalence of H. pylori in patients with ITP. [Lancet 1998;352(9131):878, Am J Hematol 2000;65(4):329-30] Plausible mechanisms include molecular mimicry and cross reactivity of platelet and bacterial antigens, in association with host factors HLA class II alleles. H. pylori induces antibody production in response to antigens that cross react with platelet glycoprotein. Eradication of H. pylori has been shown to result in clinical benefit to some patients and result in platelet recovery, followed by disappearance of autoantibodies. [Am J Hematol 2000;65(4):329-30] In summary, for ITP, there seems to be a

H. pylori infection should precede the development of the disease In summary, in ischemic heart disease and H. pylori, the association seems to be weak and the epidemiological data conflicting. Although there is a plausible mechanism, it is not a great explanation. There are no good data to suggest that H. pylori eradication is associated with low rates of ischemic heart disease, said Tan. The role of H. pylori in Parkinson's disease, Alzheimers and urticaria has also been proposed. Although there are data suggesting an association, the studies were mostly small and need to be confirmed with a larger study, he added. Tan was speaking at the 2nd Asian Pacific Meeting on Helicobacter Pylori in Kuala Lumpur.

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17 15-31 March 2012 Regional

Survey reveals unmet needs in schizophrenia management
Christina Lau chizophrenia patients are more willing to be treated with long-acting injectable atypical antipsychotics, but are frequently turned down by their physicians when requests for such medications are made, according to a local survey. The Hong Kong Familylink Mental Health Advocacy Association interviewed 270 schizophrenia patients and their family members in 2011 to investigate patients medication use, knowledge of available medications and their healthcare needs. The mean age of the patients and caregivers was 42 and 51, respectively. More than 90 percent of patients in the survey were on oral antipsychotics. However, 48 percent had discontinued oral medications on their own. While 33.9 percent of patients or family members had asked doctors for newgeneration oral antipsychotics, such requests were turned down 26.4 percent of the time. Nearly half of the respondents believed that new long-acting injections are as effective as and more convenient than oral antipsychotics. For these reasons, they indicated a higher willingness to be treated, reported Dr. Marcus Chiu, of the department of social work, Hong Kong Baptist University, at a press conference. Although 64.7 percent of the respondents had asked doctors for long-acting injections, such requests were turned down 66.7 percent of the time. Schizophrenia patients often

Dr. Sik-Chuen Ting and Dr. Marcus Chiu.

discontinue oral medications because of forgetfulness, side effects and misperceptions that their condition has improved. While atypical oral antipsychotics are associated with fewer side effects, compliance remains a problem as long-term treatment is required, said Dr. Sik-Chuen Ting, specialist in psychiatry. Long-acting injectable atypical antipsychotics can improve compliance and, therefore, reduce the risk of recurrence as the injections are administered by healthcare professionals every 2 or 4 weeks. However, these injections are not commonly used in clinical practice because of cost constraints. Furthermore, previous research indicates that healthcare professionals often believe injections would cause pain and that patients would be reluctant to change treatment. Patients compliance with oral antipsychotics has also been overestimated. [J Clin Psychiatry 2004;65:120-31] Use of long-acting injectable atypical antipsychotics is associated with a healthcare cost saving of HKD 50 million per year compared with oral medications,

18 15-31 March 2012 Regional

said Chiu, who was referring to a retrospective study conducted by the Chinese University of Hong Kongs School of Pharmacy in 2003-2007. The researchers thus suggested that the Hospital Authority provide atypical antipsychotics, such as long-acting injections for schizophrenia patients, to reduce additional costs associated with managing relapses.

Health education key to tackling chronic diseases

Rajesh Kumar ealth education remains the key to tackling a global epidemic of lifestyle diseases including diabetes, heart disease and obesity, according to an expert. Professor Gerard de Pouvourville, chair of health economics and management at the ESSEC business school, Singapore, was speaking at the launch of the European schools Institute of Health Economics and Management for Asia Pacific.

We hear of a global epidemic of metabolic and cardiovascular diseases. But public health experts agree this could have been avoided through health education and early intervention decades ago, before it reached the current stage. Now, we are wondering how to roll it back and how to manage it effectively, said Pouvourville. Giving the example of France, which recently cut primary healthcare funding following concerns over excessive use of GP services and medicines, Pouvourville said those are precisely the type of errors we need to avoid now if we really want to address prevention. But the new economic reality is that all countries, rich or poor, need to improve the management of their scarce healthcare

resources to tackle these challenges more effectively, he said. Market and industry research indicates a growing demand for accessible, high-quality healthcare services and health insurance throughout the Asia-Pacific region. And the institutes research and training programs could help generate new ideas and innovations from the region itself, he said. The new institute will be dedicated to research and development in health technology assessment, strategic hospital man-

... the institutes research and training programs could help generate new ideas and innovations from the region itself agement, healthcare services funding and organization, health insurance economics, and the impact of health regulations on biomedical innovation and market access. It has already garnered strong interest in the region through education grants from healthcare companies including Johnson & Johnson, Medtronic, sanofi, UCB and Vifor Pharma. Its inaugural program in health technology assessment: definitions, objectives, methodologies and contributions to decision making process attracted the regions key healthcare policymakers, health insurers and providers in-charge of designing and implementing rules and regulations for the access to healthcare technologies in their respective countries.

19 15-31 March 2012 Regional Coffee may reduce fibrosis risk in patients with NASH
Elvira Manzano ncreased intake of coffee may hold the key to decreasing the risk of advanced fibrosis scarring in people with fatty liver disease, research suggests. In a study of 306 patients with nonalcoholic steatohepatitis (NASH), high consumption of coffee significantly decreased the formation of excess fibrous connective tissue in their liver. [Hepatology 2012; 55(2):429-36. doi: 10.1002/hep.24731] Our study is the first to demonstrate a histopathologic correlation between fatty liver disease and estimated coffee intake, said study author Dr. Stephen Harrison, lieutenant colonel in the US Army based at Brooke Army Medical Center in Fort Sam Houston, Texas, US. Moderate coffee consumption may be a benign adjunct to the comprehensive management of patients with NASH. Harrison and his team studied the coffee consumption of participants from a previous non-alcoholic fatty liver disease (NAFLD) study and NASH patients treated at the centers clinic and categorized them into four groups patients with no sign of fibrosis (controls), steatosis, NASH stage 0-1, and NASH stage 2-4. There was a significant difference in the caffeine consumption of patients with steatosis compared to patients with NASH stage 0-1 (P=0.005). Additionally, coffee consumption was significantly greater in patients with NASH stage 0-1 than with NASH stage 2-4 (58 percent versus 36 percent of caffeine intake from regular coffee, P=0.016).

There was a stepwise decrease in coffee consumption as fibrosis increase, Harrison explained. This would suggest that other properties of coffee beyond caffeine may affect disease progression in NASH patients. Caffeine intake has long been associated with a reduced risk of hepatocellular carcinoma, and reduced fibrosis and cirrhosis in patients with chronic liver diseases such as hepatitis C. [Hepatology 2009;50:1360; Hepatology 2010;51:201] It has also recently been suggested that coffee may protect against diabetes and endometrial cancer. Knowing the beneficial effects of coffee intake on liver diseases, future prospective research should examine the amount of coffee intake on clinical outcomes, Harrison concluded. Commenting on the study, Dr. Vincent Wong, professor, department of medicine and therapeutics director, Center for Liver Health, The Chinese University of Hong Kong said the current paper adds to the existing literature showing that the same phenomenon is observed in NAFLD patients. The study has a relatively large sample size. The existing literature is rather consistent on the association between coffee intake and liver injury. However, limited by the nature of observational studies, causal relationship is difficult to establish, he said. For example, instead of direct causal effect, coffee intake may be associated with less liver fibrosis through differences in smoking, alcohol use and physical activity.

20 15-31 March 2012 Regional Non-drug approaches help alleviate cancer pain
Elvira Manzano on-pharmacological, psychosocial interventions are a valid and effective option for the treatment of pain in patients with cancer, according to a recently published meta-analysis. Pain is one of the most common, burdensome and feared symptoms experienced by patients with cancer, said Dr. Paul B. Jacobsen, lead study author and associate director for Moffits Division of Population Science, Tampa, Florida, US. The positive findings from this meta-analysis considerably advance support for the importance of psychosocial interventions in reducing pain in cancer patients. Jacobsen and colleagues analyzed 37 randomized controlled studies of psychosocial interventions involving a total of 4,199 adult patients with cancer. The studies were published between 1966 and 2010. [J Clin Oncol 2012. Jan 23. Epub ahead of print] Across the studies, psychosocial interventions were found to provide weighted averaged effect sizes of 0.34 (95% CI 0.23-0.46; P<0.001) for pain severity and 0.40 (95% CI 0.21-0.60; P<0.001) for pain interference. In interpreting their results, the authors concluded that such interventions provided medium-sized effects in statistical terms, in terms of reducing pain severity and the degree to which pain related to cancer and its treatment interfered with patients lives. They also revealed that skill-based approaches, for example relaxation and hypnosis, tended to be more effective

Relaxation and hypnosis reduce pain in cancer patients.

at reducing pain severity compared with educational approaches, such as teaching patients how to use their medications. Psychosocial interventions on the whole do work, said Professor Cynthia Goh, senior consultant, department of palliative medicine, National Cancer Center Singapore. The findings are relevant because the article looks at how good the evidence is for psychosocial interventions to alleviate cancer pain, she said. It is very important for patients to understand their pain and learn how to control it with the help of their doctors and therapists. Sometimes, a simple explanation repeated as necessary is enough to help a patient learn how to take their medicines for pain and for treatment of side effects, or how to avoid certain situations which

21 15-31 March 2012 Regional

make the pain worse so they can feel they are in control, Goh explained. But in some chronic pain situations, patients need more than explanations given at a medical consultation. Sometimes, they need to go through certain kinds of training to help them think about their pain in a different way, or change their behavior which makes the pain worse. She said these kinds of training may be done in a group, or individually. I have seen patients who have undergone cognitive behavior therapy and benefited from it. Other interventions include more contact with a nurse or a therapist for followup and education about their pain. Goh said the study has been carefully done and the information it provides is valuable and adds to existing knowledge. I think it is important that any interventions be properly evaluated through randomized controlled trials, and meta-analyses of such trials. But it is particularly important when it comes to psychosocial interventions, as there is less standardization of such interventions, and many medical doctors, who are more used to prescribing drugs or doing operative procedures, are less convinced of their efficacy. Up to one-third of cancer patients suffer from moderate to severe pain which interferes with sleep, daily life activities, enjoyment of life, work ability and social interactions.

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22 15-31 March 2012 Regional Further curbs on obstetric services for non-locals in HK
Naomi Rodrig

gainst growing public discontent denouncing the increasing number of mainland Chinese women giving birth in Hong Kong, the Hospital Authoity (HA) recently reviewed and revised its regulations on obstetric service provision in 2013. A review of the 2012 delivery bookings by the HAs Taskforce on Obstetric Services for Non-eligible Persons (NEP) showed that there is a higher demand from local expectant mothers than the original forecast, the HA spokesperson said.

2013 and the consequent demand for neonatal services, the taskforce reiterated the priority for local pregnant women in booking of obstetric services, and proposed a preliminary plan on quotas for non-locals in 2013. The prime responsibility of our hospitals is to ensure adequate and up-to-standard services for local mothers as well as newborns. We will closely monitor the service booking situation and adjust the service quota to ensure local demand is always met, said Dr. Wai-Lun Cheung, HA Director (Cluster Services) who chaired the meeting. The taskforce recommended that four

As a result, Princess Margaret Hospital has ceased to accept bookings from non-local mothers for the rest of 2012, while Queen Mary Hospital will also reduce the obstetric quota for non-locals in coming months. Last year, about 41,000 mainland NEP gave birth in Hong Kong hospitals, accounting for nearly half of the total births in the city. Given the burden on the obstetric and neonatal units with the surge in non-local expectant mothers using public hospital services, the government has limited the number of non-local births in the city in 2012 to 34,000. While described as a step in the right direction, it does not address the plight of local pregnant women who often are unable to reserve hospital beds for delivery because of the influx of non-locals. Having considered the service capacities and priorities for local expectant mothers in

We will adjust the service quota to ensure local demand is always met public hospitals (Kwong Wah, Princess Margaret, Prince of Wales and Tuen Mun) not accept any bookings of non-local mothers next year, while the quota of the remaining four hospitals (Pamela Youde Nethersole Eastern, Queen Elizabeth, Queen Mary and United Christian) will be further reduced to below 3,000 in total. The proposed plan will be submitted to the Food and Health Bureau for consideration against the supply and demand situation of obstetric services in both the public and private sectors. As complementary measures, the government is tightening up the borders and cracking down on so-called birth agents shuttling mainland women into the city to give birth. In mid-February, a mainlander who brought pregnant women into Hong Kong was sentenced to 10 months in prison.

MTFEB15-12/001

24 15-31 March 2012 Regional

Removing the root of cancer
Christina Lau esearchers in Hong Kong have developed a novel class of compounds that can inhibit the growth of cancer stem cells. Cancer stem cells are a small group of cells in tumors with the ability to proliferate and self-renew, and to differentiate into heterogeneous cancer cells that constitute the entire tumor mass. Being resistant to conventional cancer therapy, they are very difficult to eradicate and are the source of relapse and metastasis. In a joint study by the Hong Kong Polytechnic University (HKPU), Peking University Shenzhen Graduate School, and Nevada Cancer Institute in Las Vegas, US, researchers have developed a novel class of compounds that could inhibit the growth of cancer stem cells. [Cancer Res 2011;71:7238-49] The compounds were specific bioactive small inhibitors of lysine-specific demethylase 1 (LSD1), a histone demethylase that is highly expressed in many tumors.

of LSD1 inhibitors include treatment of malignant germ cell tumors, such as teratomas or teratocarcinomas, embryonic carcinomas, seminomas, choriocarcinomas, and tumors of yolk sac,

These LSD1 inhibitors were found to inhibit the proliferation of pluripotent cancer cells, including teratocarcinoma, embryonic carcinoma and seminoma or embryonic stem cells expressing the stem cell markers Oct4 and Sox2. However, there was little growth-inhibitory effect on non-pluripotent cancer cells or normal somatic cells. The potential clinical applications

The compounds can also be used to remove teratomas ... which often become resistant to initial platinum treatment, said Dr. Tao Ye, of HKPUs department of applied biology and chemical technology who led the study. The compounds can also be used to remove teratomas or embryonic carcinomas during stem cell-based therapy and to inhibit organ-specific cancers with stem cell-like cells, such as breast and ovarian cancers.

25 15-31 March 2012 Regional Even elderly smokers benefit from quitting
Radha Chitale

ong-term smokers who quit, even those over 60, experience significant health benefits within 5 years, according to a Singapore study. Lead researcher Dr. Woon-Puay Koh, an epidemiologist at the National University of Singapore, said the purpose of the study was to determine how rapidly those who quit smoking were able to see substantial results. One of the most common reasons for not quitting smoking in an elderly person is: Well Ive always smoked for so long, and Im already at this age ... If I quit now, will I have any benefit to quitting compared to someone who has just started smoking and quit quickly? she said. Using data from the Singapore Chinese Health Study, a cohort of 52,322 adults aged 45 to 74 years were surveyed twice about their medical history, smoking status and other lifestyle factors first between 1993 and 1998 and again between 1999 and 2004. [Tob Control 2011 Dec 14. Epub ahead of print] According to data from the 2010 National Health Survey, 14.3 percent of Singaporean men and 4.2 percent of Singaporean women smoke, and the current studys predominantly male subject group reflected that. Participants were grouped into never smokers (72.5 percent), long-term quitters (8.9 percent; quit before recruitment, mean 17 years), new quitters (3.6 percent, quit between recruitment and follow up, mean 4.3 years) and current smokers (15 percent). Mean follow up was 8.1 years. After adjusting for lifestyle, new quitters and long-term quitters reduced their risk of death from lung cancer by 24 and

56 percent at follow up, respectively, compared with current smokers. Risk of total mortality fell by 16 and 29 percent among new and long-term quitters, respectively. The risk reductions held true after further adjustment in which participants with chronic diseases were excluded from analysis (N=36,387). Whats interesting is that in this group of new quitters that we have studied, they have smoked an average of 39 years, Koh said. So these are really long-term smokers who at the age of 60 decided to quit, and we do see benefits. Cessation was also associated with a non-significant reduced risk of coronary heart disease and almost no difference in stroke-related mortality. Long-term quitters showed a 32 percent reduced rate of COPD-related death, but this rate increased among new quitters by 23 percent. The mechanics of lung repair compared to circulatory replenishment may explain the differences in the short-term effects of cessation on lung disease versus heart disease. Structural damage to the lungs may take years to reverse, while the effect of smoking on circulation may be relatively faster to reverse, Koh said. In addition, new quitters are more likely to stop smoking because they are experiencing health problems and so is a group that, as a whole, may be more sick than long-term quitters or current smokers. Based on their results, Koh noted that in addition to smoking prevention, public health strategies targeting cessation in current smokers, even those over age 60, could yield health benefits.

MTMAR15-12/001

27 15-31 March 2012 Regional Pediatric EEG commonly misused in Hong Kong
Naomi Rodrig

local study has found that nearly half of the referrals for standard electroencephalography (EEG) in pediatric practice are inappropriate, prompting the authors to call for more judicious use of the test based on current guidelines. [Hong Kong Med J 2012;18:25-9] Investigators from the department of pediatrics and the Electrodiagnostic Medical Unit at Tuen Mun Hospital evaluated the records of 109 children who underwent standard EEG between December 2009 and February 2010. Overall, 44 percent of the EEG requests were inappropriate with respect to guidelines, of which 50 percent were for the diagnosis of funny turns, 23 percent for febrile convulsions and 23 percent for monitoring patients with established epilepsy. According to the guidelines, standard EEG is not recommended in these conditions as it is not helpful or even misleading. Conversely, EEG referrals are appropriate in case of definite or probable epileptic seizures and classification of newly diagnosed epilepsy, as well as in cases of encephalopathy, neuro-degeneration and organic brain disturbances. Of the appropriate requests in the study, 89 percent were correctly made to support a diagnosis of epilepsy based on strong clinical suspicion. Interestingly, both specialists and nonspecialists made inappropriate referrals for EEG (45 and 40 percent, respectively). The authors suggest that unrestricted access to standard EEG in Hong Kong hospitals

leads to unjustified requests, in particular from nonspecialists (86 percent of the 109 cases). There is considerable potential for unnecessary requests and misinterpretation of the results, claimed WC Lee et al. Importantly, the EEG results often do not contribute to clinical management. In the study, EEG results did not affect subsequent management in all inappropriate referrals as well as in 49 percent of appropriate referrals. Overall, the standard EEG contributed to the diagnosis or management in only 28 percent of patients, they wrote. These data confirm previous overseas reports that misconceptions about the diagnostic capability of EEG are common, leading to abuses. The authors believe that suboptimal use of the EEG service is typical of most regional hospitals in Hong Kong and the study results can be generalized. They specifically warn of EEG misuse to exclude epilepsy, which is almost impossible, as the diagnosis of epilepsy is clinical. Moreover, so-called false-positive EEG findings can be as high as 0.5 percent This increases the risk of misdiagnosing epilepsy and its attendant important consequences, including inappropriate drug treatment and the psychological trauma of being labeled epileptic, they wrote. Attributing the pediatric EEG abuse to misconceptions regarding its role and limitations, the investigators suggest that physician education may help. Through an educative, non-confrontational approach, and with time to explain guideline recommendations to clinicians, sustainable change in practice could be achieved, they recommended.

28 15-31 March 2012 Regional AF patients on warfarin warned about herbal foodstuffs
Christina Lau atients with atrial fibrillation (AF) treated with warfarin should watch out for a number of foods and herbs commonly used in Chinese cooking, as frequent consumption of these ingredients is associated with suboptimal anticoagulation control in a recent study. Many AF patients know that warfarin interacts with green leafy vegetables and beans, which contain large amounts of vitamin K. But few are aware that foods with herbal ingredients used in Chinese cooking may augment or inhibit its anticoagulation effect, said Professor Hung-Fat Tse, of the division of cardiology, University of Hong Kong, who led the study. The study included 250 patients with nonvalvular AF who had been treated with warfarin for at least 6 months. They were asked about consumption of foods with herbal ingredients that may interact with warfarin in the past 12 months using a standardized questionnaire. The researchers then investigated the effect of the concomitant consumption on INR (International Normalized Ratio) control. [J Cardiovasc Pharmacol 2011;58:87-90] Up to 50 percent of patients reported consumption of foods with herbal ingredients that may interact with warfarin. The most commonly consumed foods were garlic (80 percent), ginger (75 percent), papaya (55 percent), green tea (50 percent), ginkgo (40 percent) and Chinese

Table. Foods with herbal ingredients that may interact with warfarin.
Increase INR/augment the effect of warfarin:
Chinese wolfberry () Danshen () Devils claw () Dong quai () Fenugreek () Feverfew () Garlic Ginger Ginkgo Papaya

Decrease INR/inhibitory effect of warfarin:

Ginseng Green tea

St Johns wort

Adapted from J Cardiovasc Pharmacol 2011;58:87-90.

wolfberry (25 percent). Herbal drugs such as ginseng (4 percent), danshen (1.2 percent) and dong guai (0.8 percent) were uncommonly consumed. Importantly, frequent users who consumed more than one kind of herb for at least four times per week were less likely to stay within the optimal therapeutic INR range of 2-3 than infrequent users who consumed one kind of herb for fewer than four times per week, pointed out Tse. Frequent users had their INR out of optimal therapeutic range 49 percent of the time, compared with 42 percent of the time for infrequent users. This study highlights the issue of limited knowledge in warfarin-treated AF patients of the potential interaction between herbal substances in foods and warfarin, he continued. Although we did not measure the amounts of foods with herbal ingredients consumed by the patients,

29 15-31 March 2012 Regional

over-consumption of such foods may affect INR control, increasing the risk of stroke or bleeding. Tse suggested that warfarin-treated patients should be educated on the foods and ingredients that can potentially affect INR. Dietary restrictions and regular monitoring are important to make sure that INR is maintained within the optimal therapeutic range.

Cough medicine abuse linked to muscle damage

Naomi Rodrig

ough mixture overdose has been associated with severe folate deficiency, which may cause rhabdomyolysis, as demonstrated in several case reports featured recently in the Hong Kong Medical Journal. [Hong Kong Med J 2012;18:68-9] According to study authors, from the department of psychiatry at Kwai Chung Hospital and the department of medicine at Queen Mary Hospital, cough mixture abuse is an emerging problem among young men, and its metabolic consequences have been recognized only recently. These include severe renal damage, metabolic acidosis, and severe folate deficiency that can lead to neurological and hematological effects. However, musculoskeletal side effects have not been recognized as yet. They reported three cases of young men (age 29 to 32), who presented with confusion, uncoordinated limb movements, rigid limb tone, myalgia and muscle weakness. All patients had a history of antipsychotic drug abuse and cough medication overdosing (30 cough tablets or >2 bottles of cough syrup daily), and were diagnosed with folate deficiency (125, 63 and 61 g/mL versus reference level of >164 g/mL). An open muscle

biopsy in one of the patients showed necrotizing myopathy with degenerating fibers and sarcoplasmic vacuolation, while a sural nerve biopsy showed severe axonal degeneration. Rhabdomyolysis is an uncommon clinical emergency related to illicit drug and alcohol abuse; it may result in renal shutdown, hyperkalemia, hyperphosphatemia and death. After excluding the initial differential diagnoses, the authors concluded that folate deficiency was implicated in the muscle damage, although myoglobinuria was documented in only two of the patients. Large doses of codeine as well as low folate levels are known to have myopathic effects. All these are suggestive of a causative effect. Interactions with other components (eg, pseudoephedrine), impurities or additives in the illicit cough mixture might also aggravate the musculoskeletal damage, they wrote. They pointed out that cough mixture abuse is often perceived as relatively harmless, but in fact may have damaging metabolic and neuropsychiatric sequela. Therefore, they suggest a high index of suspicion, so clinicians can initiate early investigation and treatment to minimize any permanent muscle or kidney damage.

Further information is available upon request. * References on file.

31 15-31 March 2012 International Dual-arm BP difference may indicate vascular disease
Leonard Yap arge differences in blood pressure (BP) measurement between both arms may prove to be a useful indicator of increased risk of vascular disease and even death, according to a UK study. Researchers at the University of Exeter Peninsula College of Medicine and Dentistry (PCMD) found that differences of 15 mmHg or more in systolic BP measurements between arms indicated an increased risk of peripheral vascular disease (the narrowing and hardening of the arteries that supply blood to the legs and feet); cerebrovascular disease (affecting the blood supply to the brain and often associated with cognitive issues such as dementia); and mortality. The risk of peripheral vascular disease was also increased at a difference of 10 mmHg or more. The findings were published in the Lancet online and the study was supported by the Royal College of General Practitioners, the South West GP Trust and the National Institute for Health Research Peninsula Collaboration for Leadership in Applied Health Research and Care. [doi:10.1016/ S0140-6736(11)61710-8] A systematic review and meta-analysis by researchers at PCMD examined 28 papers covering differences in systolic BP readings between arms. We set out to investigate whether there was an association between differences in systolic blood pressure between arms and vascular disease and mortality. Our findings indicate a strong association, and that

Dual-arm blood pressure may give doctors a better indication of a patients cardiovascular health.

differences of 10 mmHg or 15 mmHg or more might help to identify patients who are at risk and who need further vascular assessment. However, more research is required in order to transfer our findings to clinical practice, but in the meanwhile we will be flagging the results of our review to the UK Vascular Check programme, said Dr. Christopher Clark, clinical academic fellow at PCMD and a GP in Witheridge, Devon, and lead author of the study. In an accompanying comment, Dr. Richard McManus, of University of Oxford, and Dr. Jonathan Mant, of University of Cambridge, said that the new findings reinforce existing guidance statements that recommend blood pressure measurements be taken from both arms and that this should become part of routine care, as opposed to a guideline recommendation that is mostly ignored.

32 15-31 March 2012 International Tai chi improves balance, reduces falls in Parkinsons
Radha Chitale ai chi exercises proved better at improving balance and reducing the risk of falls among adults with Parkinsons disease compared with strength training or simple stretching, according to a study. Physical activity has been shown to retard the deterioration of motor functions and to prolong functional independence, the study authors said. Patients with the neurodegenerative disease are left with impaired balance, less stability, gait dysfunction, poorer quality of life due to reduced functional abilities and an increased risk of falls. These symptoms are largely unaffected by drug therapy and exercise is recommended. However, the researchers note that resistance training, which has been shown to address balance and strength deficits, requires monitoring and equipment. We hypothesized that tai chi would be more effective in improving postural stability in limits-of-stability tasks than a resistance-based exercise regime or low impact stretching, they said. A group of 195 patients with mild-tomoderate Parkinsons disease were randomly assigned to receive twice-weekly 60-minute sessions of tai chi, resistance training or stretching (control) for 24 weeks. [N Engl J Med 2012;366:511-9] The tai chi protocol was designed to tax balance and gait by focusing on symmetric and diagonal movement, weight shifting, controlled center of gravity displacement, ankle sways, and anterior-posterior and

lateral stepping. Resistance training focused on the muscles important for posture, balance and gait, including squats, lunges and heel and toe raises, using weighted vests and ankle weights. Seated and standing stretches for the upper body and legs provided a low intensity control group. Tai chi patients performed better than the resistance and stretching groups in the primary outcome measures testing the limits-of-stability, which assesses how far patients can lean in a number of directions without falling, and at directional control, which measures movement accuracy. There were 381 falls in 76 patients overall but the incidence rate was 67 percent lower for the tai chi group compared with the stretching group (0.22 vs 0.33, P=0.005). Tai chi patients experienced marginally fewer falls than the resistance training group, whose incidence rate was 0.47, but this was not significant (P=0.05). Tai chi patients performed better in all secondary outcome measures compared with the stretching group, including gait, knee movement, functional reach, and time to stand from sitting. They performed better than the resistance group at stride length and functional reach. The effects were maintained 3 months after completing intervention. The trial did not measure the net gain of tai chi exercise but only as compared to low intensity, low impact stretching regimes. Clinically, these changes indicate increased potential for effectively

33 15-31 March 2012 International

performing daily life functions, such as reaching forward to take objects from a cabinet, transitioning from a seated to a standing position (and from standing to seated), and walking, while reducing the probability of falls, the researchers said.

Daily milk boosts brain power

Elvira Manzano requent intake of dairy food an important step to building strong bones and preventing osteoporosis also enhances cognitive functioning, recent research has shown. A cross-sectional meta-analysis of the dietary habits and mental functioning of 972 adults in the US has found that individuals who consumed dairy products once a day had significantly higher scores in memory and other cognitive tests compared with those who never or rarely consumed dairy food. Individuals with high milk consumption were also five times less likely to fail the tests compared with nonmilk drinkers. [International Dairy Journal 2011.DOI:10.1016/j.idairyj.2011.08.001] While little is known about the underlying mechanisms of dairys benefits on cognitive functioning, the authors said its unique nutrient content might play a role. Dairy foods contain a number of important nutrients such as calcium, whey protein, vitamin D, magnesium and phosphorus, said lead researcher Ms Georgina Crichton, from the Nutritional Physiology Research Centre, University of South Australia, Adelaide, Australia. Adult subjects aged 23 to 98 who were included in a community-based study of cardiovascular disease (CVD) risk factors and cognitive functioning were put through a series of brain and cognitive challenges to assess their visual-spatial, verbal and

working memory, scanning tracking and executive function. Those who scored the highest across all tests consumed the most milk and dairy products, the study found. Cognitive performance scores increased linearly across increasing categorical levels of dairy food intake for 7 out of 8 outcome measures. Milk drinkers also maintained healthier diets overall compared to non-drinkers. Frequent dairy food intake was associated with better cognitive performance across a range of cognitive domains in this dementia-free, community dwelling population, the authors said. The association between greater dairy food intake and better cognitive performance remained significant even after adjusting for several cardiovascular risk factors such as CVD prevalence, hypertension and wait circumference. While the authors said the study has a number of strengths, including large community sample, longitudinal studies are still needed to improve understanding of the association between dairy intake and cognitive function. As brain disorders are most likely to impact upon more than a single cognitive ability or behavior, cognitive function needs to be assessed with a thorough neuro-psychological test measuring a range of cognitive abilities. Frequent intake of dairy products such as milk, cheese and yoghurt has also been shown to help reduce weight and control blood pressure and diabetes, all of which are risk factors for CVD that increase the likelihood of cognitive dysfunction.

34 15-31 March 2012 In Practice Management of CHF in primary care

Dr. David Sim
Consultant, Department of Cardiology Co-Director, Heart Failure Programme National Heart Centre Singapore

Impaired pumping ability Congestive heart failure (CHF) the inability of the heart to pump oxygenrich blood sufficient to meet the bodys metabolic needs is a clinical syndrome accompanied by derangement in the neurohormonal system, the renin-angiotensin-aldosterone system and sympathetic system. Common causes of heart failure include ischemic heart disease, cardiomyopathy and hypertension. Other causes are alcoholic cardiomyopathy, valvular heart disease, thyrocardiac disease, chemotherapy-induced cardiomyopathy and viral myocarditis and in rare cases, hemochromatosis and amyloidosis. When cardiac muscles are damaged, it makes the heart less able to pump blood. Fluid accumulates in the lungs, in the abdomen, or in the peripheral tissues, a condition called fluid overload. Diagnosing CHF With proper history taking coupled with comprehensive physical exam, physicians are able to get a diagnosis. Echocardiogram may be useful but not essential for CHF diagnosis. A simple chest X-ray can detect congestion in the lung. Jugular venous
CHF is the end result of a variety of insults to the heart which in some cases may be irreversible.

pressure is often assessed as a marker of fluid status. Blood tests performed include electrolytes, renal function and liver

35 15-31 March 2012 In Practice

function tests. The serum level of B-type natriuretic peptide (BNP) or N-terminal pro b-type natriuretic peptide or (NT-proBNP) is related to the severity of heart failure. Higher levels of BNP or NT-proBNP are associated with bad prognosis. Symptoms of CHF depend on the side of the heart involved. In left-sided failure, congestion of pulmonary vasculature causes respiratory symptoms such as dyspnea on exertion or at rest, orthopnea increasing breathlessness on lying flat and paroxysmal nocturnal dyspnea. Easy fatigue and hypotension are signs of poor cardiac output. In right-sided failure, there is venous congestion leading to fluid accumulation in the feet and ankles. Ascites and hepatomegaly may also occur in progressively severe cases. Liver congestion may result in liver function impairment. Jaundice and deranged clotting may also occur. Patients with biventricular failure often present with both left and right-sided symptoms. Clinical Guidelines Physicians can refer to the American Heart Association (AHA), the American College of Cardiology (ACC) and the European Society of Cardiology (ESC) guidelines for managing heart failure. Angiotensin-converting enzyme inhibitors (ACE inhibitors)/angiotensin receptor blockers (ARBs) and beta-adrenergic blockers (beta-blockers) are the cornerstone of treatment in patients with heart failure and a reduced left ventricular ejection fraction (LVEF). Use of aldosterone antagonists is recommended in New York Heart Association (NYHA) Class III/IV patients with LVEF of <35 percent. The SEATTLE Heart Failure Model which is available online predicts mortality risk in CHF patients. It includes medications and devices used to treat heart failure and how altering these affect survival. A new mobile application, the Seattle Heart Failure Risk Calc, also provides an estimate of survival rates and average years of survival for patients with heart failure. Management approaches Treatment of CHF focuses on dietary changes and pharmacological modalities, the primary objective of which is to restrict fluid. A liter or up to 1.2L a day is recommended depending on the patients size. Sodium intake is also restricted. Some patients need to be put on diuretics when there is evidence of fluid overload. Digoxin is useful in patients with atrial fibrillation. ACE inhibitors and beta-blockers, if not contraindicated, are part of standard therapy. Besides initiating the evidencebased drugs, GPs should note the dosage. They should see the patient in 2 weeks to recheck electrolytes and renal function. If the patient is stable, uptitration of ACE inhibitors and betablockers is recommended until the maximum dose is tolerated. Clinical trials have shown that the higher the doses, the better the prognosis. Exercise is also encouraged if tolerated. New alternatives to ACEI, beta-blockers GPs and non-cardiologists should look beyond ACE inhibitors and betablockers. New drugs are available. One is eplerenone, a selective aldosterone antagonist. In the EMPHASIS-HF trial, treatment with eplerenone reduced the risk of cardiovascular deaths by 24 percent and the risk of hospitalization for heart failure by

36 15-31 March 2012 In Practice

42 percent in patients with mild symptoms (Class II). The incidence of gynecomastia seen with spironolactone is also lower. For Class III or IV patients, we use spironolactone based on the RALES trial. Another drug available is ivabradine, which in the SHIFT-HF trial was shown to decrease mortality when added to standard therapy of ACE inhibitors/ARB and beta-blockers. Ivabradine is recommended in patients with sinus rhythm with a heart rate of >70 beats per minute. Challenge to GPs CHF is the end result of various insults to the heart which in some cases may be irreversible. The key message for GPs is not just to treat CHF as a simple fluid overload issue. Patients often have other co-morbidities such as renal impairment, anemia, sleep apnea and depression. All patients with newly diagnosed heart failure should be referred for further evaluation. Once stable, patients can be managed in the primary care setting. Some patients may present without symptoms (NYHA Class I) but succumb to sudden cardiac death. The most common reasons for this are ventricular tachycardia (VT) and ventricular fibrillation (VF) in patients with poor ejection fraction. In this case, implantable cardioverter defibrillator (ICD) improves survival. Patients younger than 60 years old, with symptoms that do not improve despite optimal medical therapy, should be referred to us for transplant. New advances in CHF treatment Recently, the lack of good, healthy heart transplant donors has seen the need to improve the current generation of mechanical heart devices. The widening gap in the number of patients awaiting transplantation and hearts available for transplant has prompted efforts to make the current generation of ventricular assist devices (VAD) smaller, more convenient and totally implantable. Device therapy has started to play in selected patients with CHF. The challenge now for cardiologists is how to get rid of the driveline to eliminate potential source of infection. If the pump technology improves to a stage that survival with VAD is equivalent to heart transplantation, then transplantation may be replaced by VAD. Stem cell therapy is also being tested. This and other significant advances in drug therapy have sparked an unprecedented optimism in the treatment of CHF. We, at the National Heart Centre, Singapore, are actively taking part in clinical trials and are awaiting eagerly the results of other bigger studies. CHF is a debilitating if not fatal condition with lots of burden on the patient, the family, livelihood and the health care system. We need a multi-approach to tackle this problem.

Online Resources:
American Heart Association www.american heart.org/heart failure Heart Failure Matters www.heartfailurematters.org European Society of Cardiology www.escardio.org/communities/HFA/Pages/ welcome.aspx

37 15-31 March 2012 After Hours

Christina Lau discovers autumn colors

in Kyoto, Japan, when maple leaves were turning red in mid-November.

Kyoto
of the

Autumn in

he Japanese term momijigari (, red-leaf hunting) vividly describes the character

countrys maple leaves in

autumn. Despite meticulous forecasts of when the leaves are going to turn red in different parts of Japan, whether you catch them

38 15-31 March 2012 After Hours

Kyoto
in their most vibrant colors is a matter of luck. With the forecast that Kyoto leaves were going to start turning red in early November, we set off hoping to see stunning seas of red at scenic spots across the city by the middle of the month. But the maple leaves were just starting to turn red when we were in Kyoto. The late arrival of autumn colors did not hamper peoples spirits, as flocks of local and overseas tourists could be seen snapping pictures of any red leaf in sight. At popular attractions such as the Kiyomizu Temple () and the nearby Jishu Shrine (), young women came in kimono (traditional Japanese full-length robes) to celebrate the occasion and pray to the deity of love and matchmaking said to reside in the latter. For a break from the crowd, Sagano () in the northwestern part of the city offers tranquility at temples built more than 1,000 years ago. Many of the temples house sculptures and scriptures officially classified as National Treasures and Important Cultural Properties of Japan. These temples are also fabulous spots for red-leaf viewing, where autumn colors complement the beauty of the architecture and traditional Japanese gardens. If you want to see autumn colors in Kyoto, it is not too early to book a few months in advance. With the large number of visitors flocking to the city in November, most hotels and inns were full when we booked in September.

Autumn in

39 15-31 March 2012 Humor

Dont worry about the hallucinations youve been having lately, its only your imagination!

I know your condition is very serious, but think of all the other serious conditions you dont have!

Im the Doctor here, so I will decide if youre sick or not!

Excessive consumption of seafood like lobster, for example, can increase bad cholesterol levels or something much, much more serious!

Hes going to live, but he still thinks you should remarry!

There you are. Been waiting long?

40 15-31 March 2012 Calendar

MALAYSIAN EVENTS

March
1st World Congress on Healthy Ageing 2012 19/3 to 22/3; Kuala Lumpur Info : Secretariat Tel : (03) 2070 5600 Fax : (03) 2072 5600 Email : wcha@healthyageing.org www.healthyageingcongress.org 8th National Symposium on Adolescent Health (8th NSOAH) 23/3 to 25/3; Melaka Info : Dr. N. Thiyagar / Dr. Mymoon Alias Tel : (03) 20954784 Fax : (03) 20954784 Email : mymoon_kkm@hotmail.com / thiyagarsp@yahoo.com www.mma.org.my National TB Symposium 2012 24/3 to 25/3; Kuala Lumpur Info :Dr. Liza Ahmad Fisal / Dr. Nurhayati Mohd Marzuki / Dr. Zamzurina Tel : (03) 4023 2966 Fax : (03) 4024 4063 Email : lizafaisal77@yahoo.com / nurmm25@gmail.com / zamzurina76@yahoo.com.my www.nationaltbsymposium.webs.com The First International Conference on the Promotion of Mental Health and Wellbeing 28/3 to 30/3; Kuching

Info : Mr. Michael Murray Tel : (082) 230 597 Email : michael@cliffordbeersfoundation. co.uk www.cliffordbeersfoundation. co.uk International Academy of Periodontology 14th International Convention and Annual Scientific Meeting 29/3 to 31/3; Kuching Info : Dr. Ajay Kakar Tel : (+91) 9821015579 Email : ajay@bitein.com www.perioiap.org Endoscopy 2012 30/3 to 1/4; Kuala Lumpur Info : MSGH Secretariat Tel : (03) 4024 4700 / 4025 4700 / 4025 3700 Fax : (03) 40230 8100 Email : secretariat@msgh.org.my www.msgh.org.my

April
Nutrition and Dietetics Professional Competency Symposium 6/4 to 7/4; Kuala Lumpur Info : Ms Grace Chong Tel : (03) 2162 0566 Fax : (03) 2161 6560 Email : ndpcs@console.com.my

41 15-31 March 2012 Calendar

MALAYSIAN EVENTS
19th Annual Congress of the Perinatal Society of Malaysia 12/4 to 15/4; Petaling Jaya Info : Secretariat Tel : (03) 2615 5555 / 2615 6889 Fax : (03) 2694 8187 Email :perinatalsocietymalaysia@ yahoo.com www.perinatal-malaysia.org Annual Scientific Meeting of the Malaysian Society of Anaesthesiologists & College of Anaesthesiologists, AMM 2012 19/4 to 22/4; Kuantan Info : Secretariat Tel : (03) 4023 4700 / 4025 4700 Fax : (03) 4023 8100 Email : secretariat@msa.asm.org.my www.msa.asm.org.my 6th General Assembly of Asia Pacific Organization for Cancer Prevention (APOCP 2012) 26/4 to 29/4; Kuching Info : Professor Yip Cheng Har Tel :(03) 7949 2440 Fax : (03) 7958 6360 Email : yipch@um.edu.my/ yipch@ ummc.edu.my www.apocp.net 9th Malaysian Conference and Exhibition on Anti-Aging, Aesthetic, and Regenerative Medicine & 2nd International Congress on Anti-Aging, Aesthetic, and Regenerative Medicine 27/4 to 29/4; Kuala Lumpur Info : Secretariat Tel :(03) 4041 0092 / 4041 6336 Fax :(03) 4042 6970 / 4042 7919 Email : info@saamm.com www.saaarmm.org 14th Johor Mental Health Convention 27/4 to 28/4; Johor Bahru Info : Pn. Noor Ratna / Ms. Ng Yuen kwan Tel : (07) 237 3333 Ext. 400 / (07) 237 3333 Ext. 410 Fax : (07) 237 1396 Email : ohormentalhealth2012@gmail. com www.psychiatry-malaysia.org WFAS 2012 Malaysia: Acupuncture, Orthopedic, Cancer and Education Symposium 30/4 to 2/5; Kuching Info : Professor Liao Chunhua Tel : (03) 5510 6868 ext 683 Fax : (03) 9173 9369 Email : chliao@msu.edu.my www.msu.edu.my

May
Private Medical Practitioners Association of Selangor and Kuala Lumpur 52nd AGM & Annual Scientific Meeting 5/5 to 6/5; Kuala Lumpur Info : Secretariat Tel : (03) 4023 4700 / 4025 4700 Fax : (03) 4023 8100

42 15-31 March 2012 Calendar

MALAYSIAN EVENTS
Email : acadmed@po.jaring.my www.pmpaskl.org 15th Malaysian Society of Transplantation Scientific Meeting 2012 17/5 to 19/5; Kuching Info : Rohayah Hamzah Tel : (03) 4024 1522 Fax : (03) 4022 6882 Email : mst@acrm.org.my www.mst.org.my/main.html South East Asia International Team Implantology Annual Section Meeting 2012 23/5 to 24/5; Kuching Info : Dr. Lee Soon Boon Tel : (03) 2095 1532 / 2095 / 1495 Fax : (03) 2094 4670 Email : drleesoonboon@gmail.com www.iti.org Malaysian Endocrine & Metabolic Society Annual Congress (MAC 2012) 24/5 to 27/5; Kota Bharu Info : Secretariat Tel : (03) 7948 1888 Fax : (03) 7948 1812 Email : MAC2012kb@gmail.com AGM/Annual Scientific Meeting of the College of Surgeons, Academy of Medicine of Malaysia 25/5 to 27/5; Kuantan Info : Secretariat Tel : (03) 4023 4700/ 4025 4700 Fax : (03) 4023 8100 Email : acadmed@po.jaring.my www.acadmed.org.my

June
Royal College of Obstetricians and Gynaecologists (RCOG) 10th International Scientific Meeting 2012 5/6 to 8/6; Kuching Info : Dr. Gunasegaran Rajan Tel : (03) 6201 3009 Fax : (03) 6201 7009 Email : ogsm@myjaring.net www.rcog2012.com 4th National Early Childhood Intervention Conference 7/6 to 9/6; Sibu Info : Dr. Toh Teck Hock Tel : (084) 217 912 Fax : (084) 213 902 Emai : necic2012@gmail.com http://agapesibu.org/necic2012/ 4th Parenteral & Enteral Nutrition Society of Malaysia (PENSMA) 2012 14/6 to 16/6; Penang Info : Secretariat Tel : (03) 4023 4700 / 4025 4700 / 4025 3700 Fax : (03) 4023 8100 Email : secretariat@pensma.org www.PENSMA.org

43 15-31 March 2012 Calendar

INTERNATIONAL EVENTS

March
61st American College of Cardiology (ACC) Annual Scientific Session 24/3 to 27/3; Chicago, Illinois, US Info : Secretariat Email : accregistration@jspargo.com www.accscientificsession.org/ 15th World Congress of Anaesthesiologists 25/3 to 30/3; Buenos Aires, Argentina Info : Secretariat Email : wfsahq@anaesthesiologists.org www.wca2012.com 9th European Congress on Menopause 28/3 to 31/3; Athens, Greece Info : European Menopause and Andro pause Society Email : emas@kenes.com www.2.kenes.com/emas/pages/ default/aspx

24th European Congress of Ultrasound in Medicine and Biology 22/4 to 24/4; Madrid, Spain Info : Secretariat Email : info@euroson2012.com www.euroson2012.com III NWAC World Anesthesia Convention (NWAC 2012) 24/4 to 28/4; Istanbul, Turkey Info : Secretariat Email : nwac@kenes.com www.nwac.org

May
American Thoracic Society (ATS) International Conference 2012 18/5 to 23/5; San Francisco, California, US Info : Secretariat Email : atsinfo@thoracic,org http://conference.thoracic. org/2012/ 19th WONCA Asia Pacific Regional Conference 24/5 to 27/5; Jeju Island, S. Korea Info : Secretariat Email : admin@woncaap2012.org www.woncaap2012.org

April
World Congress of Cardiology (WCC) Scientific Sessions 18/4 to 21/4; Dubai, UAE Info : Secretariat Email : wcc2012reg@mci-group.com www.worldcardiocongress.org

44 15-31 March 2012 Calendar

INTERNATIONAL EVENTS

June
2012 Annual Meeting of American Society of Clinical Oncology (ASCO) 1/6 to 5/6; Chicago, Illinois, US Info : Secretariat Email : ascoregistration@jspargo.com http://chicago2012.asco.org/ 10th International Conference of the Asian Clinical Oncology Society 13/6 to 15/6; Seoul, South Korea Info : Secretariat Email : office@acos2012.org / scientific@ acos2012.org www.acos2012.org 15th International Congress on Infectious Diseases (ICID) 13/6 to 16/6; Bangkok, Thailand Info : Secretariat Email : info@isid.org www.isid.org/icid/

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Medical Editor Editorial Advisory Board - Malaysia Hepatology Cardiology Clinical Oncology

Dr. Kumaran Ramakrishnan

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