Medical Tribune May 2012 PH

May 2012
www.medicaltribune.com
Dramatic blood sugar control with gastric surgery
FORUM Biobanks: Research dream or ethical nightmare?
MARKET WATCH Pfizer launches pneumococcal vaccine for adults
TREATMENT FOCUS HRT in menopause: Are the benefits worth the risks?
NEWS Bergamot orange a natural supplement
May 2012
Dramatic blood sugar control with gastric surgery

Radha Chitale
astric surgery controlled blood sugar better than intensive medical therapy among obese type 2 diabetics, according to the STAMPEDE trial, the results of which were presented at the 61st Annual Scientific Sessions of the American College of Cardiology meeting in Chicago, Illinois, US. Patients who underwent Roux-en-Y gastric bypass surgery or sleeve gastrectomy achieved HbA1c control below 6 percent within a year in 42 percent (P=0.002) and 37 percent of cases (P=0.008), respectively, compared with 12 percent who received intensive medical therapy alone. [N Engl J Med 2012 Mar 26. Epub ahead of print] Despite improvements in pharmacotherapy, fewer than 50 percent of patients with moderate-to-severe type 2 diabetes actually achieve and maintain therapeutic thresholds, particularly for glycemic control, said researchers from the Cleveland Clinic in Ohio, US, Veterans Affairs Boston Healthcare System and Brigham and Womens Hospital in Boston, Massachusetts, US. Observational studies have suggested that bariatric or metabolic surgery can rapidly improve glycemic control... The trial randomized 150 obese patients (mean age 49 years, mean body mass index 36 kg/m2, mean HbA1c 9.2 percent) with uncontrolled type 2 diabetes to receive intensive medical therapy alone, medical therapy
The STAMPEDE trial showed that gastric surgery significantly lowered HbA1c levels compared with intensive medical therapy alone in obese patients with type 2 diabetes.
plus Roux-en-Y gastric bypass surgery or medical therapy plus sleeve gastrectomy. Intense medical therapy followed the guidelines of the American Diabetes Association and included lifestyle counselling, weight management, and drug therapy. Patients randomized to surgery experienced significantly more weight loss compared with those receiving medical therapy after 12 months (-29.5 kg gastric bypass, -25.1 kg sleeve gastrectomy, -5.4 kg medical therapy, P<0.001 for both) and lead author Dr. Philip Schauer, of the Cleveland Clinic, said this, more than anything else, was the likely driver for glycemic control. Mean HbA1c was 6.4 percent in the gastric bypass group (P<0.001), 6.6 percent in the sleeve gastrectomy group (P=0.003) and
May 2012 tute, Melbourne, VIC, Australia, and Dr. K. George M. M. Alberti, Kings College Hospital, London, England, said surgery would not be the universal panacea for obese patients with type 2 diabetes and pointed out that the study duration was only 1 year and that surgery has inherent hazards. [N Engl J Med 2012 Mar 26. Epub ahead of print] There is also the problem of remission versus cure, they said. Type 2 diabetes is often progressive, and worsening of glycemic control over time is likely in many patients. However, some years of improved glycemia may well result in less microvascular disease. Both the researchers and commenters called for further studies on the long-term clinical effects of gastric surgery.
7.5 percent among patients receiving medical therapy. Patients who underwent surgery also significantly reduced or halted use of glucose control and cardiovascular medications. Reductions in the use of diabetes medications occurred before achievement of maximal weight loss, which supports the concept that the mechanisms of improvement in diabetes involve physiologic effects in addition to weight loss... the researchers said. No deaths or life threatening complications occurred although four patients required a second surgery for complications. In an accompanying comment, Dr. Paul Zimmet, Baker IDI Heart and Diabetes Insti-
May 2012
Electronic skin patches for health monitoring

Radha Chitale
ltra thin electronic skin patches that wirelessly relay health information could free patients who need to be monitored from inpatient care. The technology can be used to monitor brain, heart or muscle activity in a completely noninvasive way, while a patient is at home, said Dr. John Rogers, a professor of materials science and chemistry at the University of Illinois at Urbana-Champaign, who developed the device. These new materials for electronics can intimately integrate with the human body. The electrical components of the patches are designed to withstand water, sweat and movement. Rogers and colleagues accomplished this by preparing the same silicone used in rigid electronic wafers, in thin membranes cut into a web-like mesh and integrated with silicone rubbers that are laminated to the skin like a temporary tattoo. The findings were presented during the annual meeting of the American Chemical Society, held recently in San Diego, California, US. The patchs sensor functions allow it to measure a variety of electronic metrics
including, muscle contractions, heartbeat, brain functions, temperature and hydration. Hydration looks like a very interesting [application] for us, Rogers said. Measuring skin hydration has applications in cosmetics and athletics but Rogers pointed out that certain heart conditions can be spotted based on the bodys fluid retention. The device should also be particularly useful for patients who require monitoring by electroencephalograms, electrocardiograms and electromyograms. But the patch could be used for more than skin surface applications. Rogers said they could be integrated with advanced surgical devices to feedback information, on the surface of balloon catheters, for example, to add a diagnostic function. In addition to sensory reception, the patch can also provide electrical stimuli, Rogers said, which may be useful for physical rehabilitation. The electronic skin patch can stay on the skin for about 1 week, but beyond 2 weeks the surface layer of skin cells is naturally sloughed off. Rogers said they would need to think about accommodating this exfoliation process in situations of long-term monitoring.
May 2012
Forum
Biobanks: Research dream or ethical nightmare?

Professor Alastair V. Campbell, Director of the Centre for Biomedical Ethics at the National University of Singapore, discussed the research potential of large-scale human health databases during the Asia-Pacific Research Ethics Conference, held recently in Singapore.
iobanks, large epidemiological cohorts, including past and present populations, that are associated with extensive samples of DNA and other biological materials, linked to health data, offer a rich source of information for public health research. Data capture health episodes affecting participants as they occur and are often followed up for decades. However, the possibility of information abuse or use for commercial gain is high. Creating and maintaining biobanks raises a number of major ethical questions that should be dealt with as we strive to define and defend the biocommons. Opportunities for research Biobanks warrant unusual consideration. The data they contain offer a broad range of possible research opportunities, mined from a broad range of future health information that will be captured. This is large-scale data, with many participants, making it somewhat impersonal. In addition, a range of researchers will have access to the data for a very long time. The major features that make a biobank enterprise different from a piece of research are the need for general consent, appropriate stewardship, and justified trust. Therefore, special measures are required for biobanks, rather than holding them to the
same standards of research protocol as other data sets. The UK Biobank is the worlds largest resource of genetic health and lifestyle data. It includes over 500,000 participants aged 4069 and has the unique advantage of gaining data from the comprehensive British National Health Service. This biobank took about 10 years of lead time in order to clarify the governance and ethical framework, in addition to public consultations. People would get a letter inviting them for an assessment at a clinic. A major part of the visit was spent explaining what they were giving consent to. Participants in the UK Biobank consented to access to medical records for the remainder of their lives and after their death, without feedback on the results of their testing, other
May 2012
Forum
This kind of data consolidation lends itself to growing into virtual biobanks. Virtual biobanks are gaining popularity as researchers push to share and use population information across regions. The issue of access is important in the face of pressure to link data sets internationally but it is complicated because there is no consistency in governance across international biobanks. Ethicists could discuss whether it is right to trust international entities with biobank data without international consistency. Security measures are important to have in place to prevent inappropriate access. Stewards must address who has access to the biobank data, to what extent access to other records is controlled and how easy it is to hack into the resource. Safeguards to prevent abuse One solution could be for a virtual biobanks to link registries with safeguards to prevent identification. A person would be assigned a serial number and the serial number is linked to the health data as a way to store data without compromising the safety of the subject. The link would be stored with an independent trusted third party and without their cooperation, no one can link the health information back to the original subject. Whatever the problems with broad consent, presumed consent is not sufficient. Biobanks are more than just a collection of tissue or data. Researchers have to see these as public property for the common good, uninfluenced by commercial or nationalist interests. The prospect for large-scale data sharing for health not profit could lead to greater information and more justice in healthcare.
than minor initial tests for basic things like blood pressure levels. Consent for use of participant data is rescindable but not conditional. That is, you cannot specify what type of research you are willing to allow your tissues to be used for. The big brother scenario The nightmare scenario would be that big brother is watching. How can we be sure such databases wont be used in ways other than what the participant signed up for? If, for example, stored genetic information could be accessed by court order in a society where authorities increasingly want access to citizens? In addition, if the commercial dominates, the whole purpose of the collection is in danger. This is where ethics in governance comes in. If the ethics governing body believes the participants trust was abused, they say so, acting as proxy for the people involved. The governance of the UK Biobank is independent, and they alone guard the ethics and governance framework. They advise on revisions, monitor the UK Biobank and report their findings publicly and provide general advice.
Creating and maintaining
biobanks raises a number of
major ethical questions that should be dealt with as we strive to define and defend the biocommons Biobanks can be built from the ground up, as the UK Biobank was, but they can also be created by linking existing collections of tissue and registry information.
May 2012
Philippine Focus
PhilCAT, DOH celebrate World TB Day

Gabriel Angelo Sembrano, RN
ast March 12, 2012, the Philippine Coalition Against TB (PhilCAT), along with the Department of Health (DOH) and other stakeholders, celebrated World TB Day with a strong cry: Stop Tuberculosis (TB) in my lifetime! Ours is a daunting task and we know that only through continuous cooperation and synchronized actions can we attain our targets and goals. We also engage all stakeholders, not only organizations and government agencies, but private individuals as well. The fight versus TB concerns us all, PhilCAT national chairperson Vincent Balanag Jr. said during the event. The event stressed that efforts against TB should focus on the often neglected but highly vulnerable sector, the children. According to the WHO, around 250,000 children get infected and 100,000 of them succumb every year from TB. Childhood TB is associated with infected parents and other adults who are potential
transmitters that inadvertently pass on the infectious agent to children. Childhood TB significantly contributes to the TB morbidity and mortality in the country. Up to 50% of untreated infants and 15% of older children that has inactive TB will eventually develop to a disease within two years. Health experts suggest that if we control this disease among adults, TB incidence will automatically taper since this is the main hindrance in achieving zero Childhood TB. DOHs answer to this is the National Tuberculosis Program, with Directly Observed Treatment Short-course (DOTS) as one of its strategies. The NTP later on adopted the Public-Private Mix DOTS (PPMD) strategy, designed to increase case detection and to synchronize all TB care providers in managing their TB patients. Thus, PhilCAT advised that it is high time to prioritize childhood TB, advocate for addressing the challenges and grasp the opportunities in its prevention and control.
May 2012
Philippine Focus
First Viet Duc-PGH live telecon

Dr. Yves St. James Aquino
he first live, interactive laparoscopic teleconference between the University of the Philippines-Philippine General Hospital (UP-PGH) and Viet Duc 2012 2 15-30 April University Hospital in Hanoi was conducted by the UP-PGH Department of Surgery last March 28, 2012. An Internet link was set up between UP-PGH and Viet Duc, which is considered the largest surgical center in Vietnam, along with five of Viet Ducs satellite hospitals in Bac Ninh, Phu Tho, Son Tay, Thanh Hoa and Benh vien Nhi. The first hour saw Viet Duc Hospital demonstrate a laparoscopic procedure with single incision port for left adrenalectomy performed on a 34-year-old male patient by a surgical team led by Professor Tran Binh Giang. And in the second half of the conference, UP-PGH demonstrated a laparoscopic common bile duct exploration performed on a 19-year-old female patient by primary surgeon Dr. Crisostomo Arcilla Jr., assisted by
Regional
Dr. Dante Ang and with annotation from Dr. Ramon de Vera. The long-term benefit of this would be in terms of teaching, in terms of education. We learn from each other and we save [money] because we dont travel anymore to see what other surgeons in some parts of Asia are doing, said Dr. Serafin Hilvano, former department chair and a coordinator with the Asia Pacific Advanced Network (APAN) Medical Working Group. Hilvano added that the teleconference would be the first in a series of activities being planned with other foreign universities, as part of APANs thrust on promoting collaborations among medical institutions across Asia and the Pacific. Current chair of the surgical department in UP-PGH, Dr. Eduardo Gatchalian, was also in attendance during the teleconference, and he expressed gratitude to the people from both universities for helping make the live teleconference a success.
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May 2012
Philippine Focus
CONFERENCE COVERAGE
2012 Philippine Society of Endocrinology and Metabolism Annual Convention, 22-23 March, Manila Philippines
Increasing detection of thyroid incidentalomas cause more diagnostic concerns

Dr. James Salisi
echnological advances in imaging devices have increased the detection rates of clinically silent nodules such that there has been a sharp increase in the prevalence of thyroid incidentalomas, more specifically microscopic papillary cancer, said Dr. Thelma Crisostomo, chief of the Section of Endocrinology and Metabolism in Makati Medical Center. However, this has given rise to a clinical management dilemma and controversy since the mortality rate from this type of cancer has been stable and has not varied with the increased detection rate, she added. The recent clinical practice guidelines on thyroid incidentaloma presented by Crisostomo stated the following: More malignancies are discovered which are papillary microcarcinoma, but these are indolent, have excellent response to treatment and generally with low mortality; Fine needle aspiration biopsy (FNAB) for the high risk group or those patients with worrisome features; Non-surgical approach for low risk nodules with benign features; Thyroid lobectomy alone may be sufficient for small (less than 1 cm), low risk unifo-
cal, intrathyroid PTC (parathyroid carcinoma) in the absence of cervical nodal metastasis; and RAI (radioactive iodine) is not indicated for patients with unifocal cancer less than 1 cm. According to Crisostomo, increased diagnostic scrutiny gives rise to a management dilemma since the detection of these nodules raises the question of cancer. A two-fold increase in cancer incidence has been shown to be caused by increased sensitivity of imaging devices like high-definition ultrasonography, MRI, CT and PET scans. Mortality from this type of cancer however has remained stable at 0.5 deaths per 100,000 and this is because majority of incidentalomas have a benign or indolent nature, she added. Nevertheless small nodule sizes are not a guarantee that the mass is of low risk. Papil-
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poechogenicity, irregular margins, or abnormal lymph nodes are detected in conjunction with history and physical examination. The next step would be to biopsy the patient, which is influenced by a combination of patient characteristics and findings on ultrasonography. Ultrsonographic features that guide decision to biopsy include the size, nature, presence of calcifications and echogenicity of the nodules. The strongest indications for a patient to be biopsied are patient with high-risk history, with suspicious sonographic features, and with solid to cystic features of nodules. The tumor threshold size of a nodule for FNAB is > 1cm with characteristic isoechoic or hypoechoic appearance on ultrasound. FNAB is not indicated for purely cystic nodules. Microcalcifications are bright foci smaller than 2 mm and are common in papillary cancer. They are calcified psammoma bodies and as such are a specific feature for malignancy. Solid nodules have higher risk of malignancy, mixed nodules have less risk for malignancy, cystic are more likely benign. Many studies find overlap in features of malignant and benign nodules. In the end a single ultrasound feature cannot accurately predict malignancy. Surgery is reserved for malignant lesions while observation is done for benign lesions. Low-risk patients are recommended to have periodic ultrasound every 6 months to 12 months then 1 to 3 years to evaluate for growth; low risk and high risk patients with suspicious features are for ultrasound guided FNAB, concluded Crisostomo.
lary cancer is the most common type of thyroid nodule malignancy. Papillary mircrocarcinomas however do not manifest as overt disease, some invade the lymph nodes but available research show that mortality range from 0.15 % to 5%. Recurrence is low but some are quite aggressive with 33% of small thyroid cancers having extra thyroidal invasion. For incidentalomas, 44% had extrathyroidal invasion, 50% had regional node metastasis, with 12% malignancy rate. According to Crisostomo, investigation of a thyroid incidentaloma should be done in a systematic and cost-effective manner. A balance between curing the ill while not harming those who are not ill must be found. With this in mind, the guidelines advice prudence in subjecting patients with incidentaloma to fine needle aspiration biopsy. Definitely, not all patients presenting with small thyroid nodules found on ultrasonography should undergo biopsy, said Crisostomo. The gold standard for diagnosing thyroid nodules is gland resection and histopathologic examination. But not all patients with thyroid nodules should be subjected to surgery or even FNAB. Deciding which lesions should be treated is the key step in managing the disease. Thyroid nodules are commonly seen in women, in areas where diet has low iodine intake and in populations exposed to ionizing radiation. The prevalence of thyroid incidentalomas by ultrasonography varies, ranging from 30 to 67%. This tool can provide enormous amount of information on deciding what kind of treatment a patient should have. Malignancy is suspected once diagnostic features like solid, internal vascularity, microcalcifications, hy-
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CONFERENCE COVERAGE
BAVS stimulation in management of adrenal pheochromocytoma

Dr. James Salisi
ilateral adrenal venous sampling (BAVS) with glucagon stimulation aids in management of bilateral adrenal pheochromocytoma, a study conducted by Dr. Chandy Lou Malong et al. at the University of Santo Tomas (UST) Hospital concluded. The investigators reviewed the records of patients who underwent BAVS with glucagon stimulation from 1997 to 2010 at the UST Hospital and tracked the status of their hypertension after removal of the dominant adrenal. Majority of the patients included in the study suffered headache, paroxysmal hypertension and palpitation and 63% of them had right adrenal dominance. Mean age was 33 with highest systolic blood pressure greater than 186 mm Hg and diastolic pressure greater than 113 mm Hg. The patients had been hypertensive for more than five years and required more than three classes of anti-hypertensive drugs when they were seen at the UST Hospital. Localization and subsequent surgical removal of the dominant adrenal resulted in lower blood pressure in patients with the dis-
ease, and fewer antihypertensive medications than pre-surgery. While venous sampling is reserved for difficult cases of small pheochromocytoma and bilateral adrenal venous sampling has been used in the early detection of disease, the study demonstrated how BAVS can be used to localize the dominant side of the adrenals. Glucagon stimulation identifies the dominant lobe of bilateral adrenal pheochromocytoma by comparing the differences in epinephrine and norepinephrine post-challenge between the right and left adrenal. Identification of the dominant adrenal in turn guides the surgical management to relieve hypertension and prevent fatal cardiovascular outcomes. Patients with pheochromocytoma exhibit symptoms such as headache, anxiety, diaphoresis and palpitations as consequences of catecholamine secretion of the tumor. Pheochromocytoma occurs in 2 to 8 of 1 million persons per year, and about 0.1% of hypertensive patients have it. It is one of the correctable causes of hypertension and its removal can prevent fatal outcomes.
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Philippine Focus
CONFERENCE COVERAGE
Pre-IGT state shows other abnormal blood glucose parameters

lycosylated hemoglobin (HbA1c) and second hour glucose level after oral glucose tolerance test (OGTT) were significantly increased in individuals in the pre-impaired glucose tolerance (pre-IGT) state versus those with normal OGTT, according to a local study done by Dr. Pilar Torres-Salvador et al., under the Section of Endocrinology and Metabolism, Department of Medicine, University of Santo Tomas (UST) Hospital. Shown as a poster presentation, the retrospective, cross-sectional study reviewed records of patients in the out-patient endocrinology clinic of UST Hospital who underwent 75 grams OGTT after being suspected of having type 2 diabetes. In the initial stage of diabetes mellitus type 2, the -cell compensates for the insulin resistance by increasing insulin secretion to maintain normoglycemia, which we termed pre-impaired glucose tolerance state, wrote the authors. The group demonstrated that in the pre-IGT state, the second-hour glucose is normal (<140 mg/dL) but the insulin levels are increased (>30 uIU/mL) after 75 grams OGTT. Based on the collected data, the researchers compared HbA1c of individuals with preIGT to those with normal OGTT. In addition, HbA1c was also correlated with the secondhour glucose and insulin levels in both groups.
According to the study, the HbA1c in the two groups were compared using the t-test, while correlation between the second-hour blood glucose level and insulin with the HbA1c was done using the Pearson correlation analysis. Results of the study showed that the second-hour blood glucose were higher in individuals with pre-IGT at ~118 mg/dL than those with normal OGTT at ~94 mg/dL (p=0.001). The HbA1c levels were also higher, with ~6.09% in the pre-IGT group compared with ~5.15% in the normal OGTT group (p<0.001). Insulin levels were also shown to be higher in the pre-IGT group at ~89.3 uIU/mL, compared with normal OGTT group at ~17.4 uIU/ mL (p<0.001). Pearson correlation (r) of the second-hour insulin and HbA1c showed r of 0.437 (p=0.011) in the normal OGTT group, while the pre-IGT group had 0.418 (p=0.017). Glucose parameters including HbA1c, second-hour blood glucose and secondhour insulin post-OGTT were higher in the pre-IGT group compared with normal OGTT group. In addition, a positive correlation was demonstrated between the HbA1c and second-hour glucose levels after OGTT among individuals with pre-IGT state, the study concluded.
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May 2012
Philippine Focus
CONFERENCE COVERAGE
50mCi RAI comparable to 100mCi for thyroid remnant ablation

retrospective cohort study showed lower dose radioactive iodine (RAI) of 50mCi is as effective as 100mCi for thyroid remnant ablation after total thyroidectomy among 74 patients with low stage differentiated thyroid cancer seen at St. Lukes Medical Center. The administered iodine activity needed to ablate the thyroid remains controversial and there is no consensus as to the recommended specific activity of RAI to ablate residual thyroid especially amongst the low-risk population, said Dr. Evan Paulo Consencino, one of the study authors. Consencino and Dr. Reynaldo Rosales with the Section of Endocrinology, Diabetes and Metabolism in St. Lukes Medical center evaluated 241 patients admitted for RAI from 2006 to 2010. Data was collected from hospital admission records, surgical pathology reports and out-patient records. Out of the 241 patients, 74 met the criteria, with 24 patients treated with 50mCi RAI and 50 patients treated with 100mCi. Clinical characteristics, tumor characteristics and treatment-related data comprise the independent variables, said Consencino. Dependent variables included adverse events, efficacy of remnant ablation, need for repeat RAI and duration of stay in the isolation unit,
he added. Successful remnant ablation is further defined as the absence of clinical evidence, the absence of imaging evidence and the absence of biochemical evidence of persistent thyroid tissue, clarified Consencino. After 6 to 12 months of the initial RAI dose, whole-body imaging and checking of serum thyroglobulin of patients were done to evaluate efficacy of remnant ablation. Study data showed 16 patients (66.7%) in the 50mCi group and 38 patients (76%) in the 100mCi group had successful remnant ablation (p=0.526). Computed risk ratio for failure of remnant ablation in the 50mCi group is 1.39 (95% CI, 0.69 to 2.94). The study also noted that there was no statistically significant difference in the need for repeat RAI between the two groups (RR 2.08, 95% CI, 0.31 to 13.91, p=0.440). Subgroup analysis was performed using criteria such as age, gender, family history of thyroid cancer, focality, lobe involvement, post-operative stage, risk recurrence and lymph node metastasis. In most criteria, failure of remnant ablation was more likely in 50mCi, but the differences were not statistically significant. Some of the most common acute adverse events noted after RAI administration included nausea (4.2% in the 50mCi group ver-
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Philippine Focus
statistically significant, patients may find it clinically significant. Our results demonstrate that the administration of 50mCi RAI is as effective as 100mCi for remnant ablation among patients with low-stage, differentiated thyroid cancer treated with total thyroidectomy. Administration of 50mCi RAI was clinically associated with fewer short-term adverse events and shorter stay in isolation, concluded Consencino.
sus 22% in the 100mCi group) and neck pain (4.2% in the 50mCi group versus 16% in the 100mCi group). Overall, reported adverse events were higher in the 100mCi group compared with the 50mCi group (36% versus 21%, respectively; 95% CI, 0.24 to 1.37; p=0.187). Study data also showed duration of hospital stay was shorter among those who received 50mCi (median 2 days) compared with those who received 100mCi (median 2.5 days). According to Consencino, although this is not
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May 2012
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Nutrition therapy education on diabetes improves patient attitude

local study by KP Sanchez et al., included among the poster presentations during the convention, showed that a medical nutrition therapy (MNT) education session could significantly increase the knowledge, skills and attitude (KAP) of diabetic patients. Coined by the American Diabetes Association, MNT is described as a nutritional diagnostic, therapy, and counseling service furnished by a registered dietitian or nutrition professional for the purpose of disease management. Through MNT education sessions, diabetic patients are able to understand the different factors that affect their health, helping them manage their condition. Sanchez et al. conducted a pre-test post-test study to 47 diagnosed diabetes type 2 patients who willingly enrolled in the Diabetic Clinic of the Makati Medical Center. The thrust of the study was to establish the effectiveness of the medical nutrition therapy education session in increasing the knowledge, skills and attitude of diabetic patients. Interventions involved nutrition counseling done by a registered dietician, as well as teaching - imparted through lectures, participatory demonstrations and discussions, coupled with visual aids like posters and charts. When the baseline scores were compared to post-test scores, the study revealed that partici-
pants were able to show significant increase of (p value < 0.05) 27.2%, 60.8% and 44.6% for their level of KAP, respectively. More particularly, although patients got decent scores in their pre-test, what was remarkable was the increase in the number of patients who got scores of above 80% in all three post-tests. According to the World Health Organization, uncontrolled hyperglycemia could lead to serious damage to many of the bodys systems, especially the nerves and blood vessels. Uncontrolled diabetes could lead to complications, organ failure and eventually death. In 2004, WHO estimated that around 3.4 million people died from consequences of high blood sugar and more than 80% of these deaths come from low- and middleincome countries. Sara F. Morris, RD, MPH, a research assistant in the Department of Nutrition at the University of North Carolina in Chapel Hill and Judith Wylie-Rosett, RD, EdD, a professor and head of the Division of Behavioral and Nutritional Research in the Department of Epidemiology and Population Health at the Albert Einstein College of Medicine in Bronx, New York said in their published study entitled Medical Nutrition Therapy: A Key to Diabetes Management and Prevention that because of the direct correlation between diet and diabetes management, MNT provided by a registered dietitian is a key complement
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Nutrition is an essential part of diabetes care since blood sugar level responds to different diets. Through MNT, diabetics would know which foods to avoid in order to maintain the right blood sugar level. Hence, complications associated with DM would be likely prevented.
to traditional medical interventions in diabetes treatment. In fact, the Standards of Medical Care in Diabetes stress that education encompasses each of the major components of diabetes treatment, namely diet, oral hypoglycemic therapy and insulin treatment.
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Philippine Focus
CONFERENCE COVERAGE
US Endo Society guidelines on vitamin D updated

he latest US Endocrine Societys Clinical Guidelines on vitamin D, which was authored by Michael J. Holick, Neil C. Binkley and others, and published last year in the Journal of Clinical Endocrinology and Metabolism, was presented by Dr. Aimee Andag-Silva, assistant professor of De La Salle University (DLSU) College of Medicine and active consultant of DLSU Medical Center and San Juan de Dios Hospital. Andag-Silva said that based on the new CPG on vitamin D, only those whose serum 25-Hydroxyvitamin D [25(OH)D] blood levels of 30 g/mL and above are getting adequate vitamin D. Any level that is lower than that is said to be insufficient, and below 20 g/mL is considered deficient. But she added that much higher level of vitamin D is better. The minimum level is at 30 g/mL, and 40 to 60 g/mL is the recommended range for both children and adults. According to the Food and Nutrition Research Institute-Department of Science and Technology (FNRI-DOST), in the Philippines, the recommended dietary intake of vitamin D is 10 to 15 g/day or 400 to 600 IU/day. In order to achieve adequacy, defined as
above 30 g/mL of 25(OH)D in the blood level, the updated CPG on the vitamin recommends that infants, those aged 1 to 18 years old, and lactating or pregnant women who belong to this age group need to have 1,000 IU of vitamin D daily. For those aged 19 years old and above, and pregnant or lactating adults, 1,500 to 2,000 IU of vitamin D daily is needed to raise 25(OH)D to greater than 30 g/mL. Andag-Silva mentioned that vitamin D is not produced by the body without the help of the ultraviolet rays from sunlight, and obtaining sufficient vitamin D from natural food sources alone is difficult. She added that although vitamin D can be found in certain foods in small amounts, it is still best to get it through sun exposure because vitamin D acquired from sunlight lasts twice longer in the body and has better bioavailability. Andag-Silva explained that the best time to get exposed to direct sunlight is between 10AM and 3PM without the use of sunscreen. Some vitamin D researchers suggest having approximately 5 to 30 minutes of sun exposure at least twice a week. Using sunscreen with sun protection factor (SPF) of 30 and above reduces vitamin D-producing UV rays of up to 95%, which conflicts with recommended practices to avoid skin cancer.
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IU/week for 8 weeks. The US Endocrine Society underscores the significance of vitamin D in achieving optimum health. It stresses that almost each single cell in the human body has an interaction with the vitamin.
In cases where vitamin D deficiency is diagnosed, the recommended values for infants and those whose age is between 1 to 18 years old are 2,000 IU/day or 50,000 IU/week for 6 weeks. For those aged 19 years old and above, the correctional dose is 6,000 IU/day or 50,000
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Philippine Focus
TREATMENT FOCUS: Hormone replacement therapy
HRT in menopause: Are the benefits worth the risks?

Dr. Adrian Paul Rabe
A few months before her 50th birthday, Diana* started experiencing hot flashes. Her husband noted decreased libido, while she complained of vaginal drying and soreness. She also felt tired and depressed despite having no new problems nor strenuous physical activity. After a few weeks of these symptoms, she consulted a gynecologist and was told that she had the classic presentation of menopause. Menopause results from the reduction and eventual loss of estrogen. It is universal among women in their late 50s, but may occur earlier through spontaneous or iatrogenic mechanisms. Hormone replacement and its benefits Hormone replacement therapy (HRT) for menopause seeks to replace lost estrogen. Some forms of replacement also contain progesterone and its derivates, as well as testosterone. The hormones may be given through multiple routes, such as tablets, patches, vaginal rings or injection. Progesterone is given primarily to oppose estrogen, particularly among patients who still have a uterus, while testosterone may be used to treat decreased libido. The general benefits of HRT include the prevention and reduction of vasomotor symptoms (hot flashes), vaginal atrophy (includes dryness, soreness, dyspareunia, nocturia),
osteoporosis, joint cartilage loss, colorectal cancer and dementia or cognitive decline. Despite these multiple benefits, only some women are able to access HRT, according to Dr. Rosiebel Esguerra, a specialist in reproductive endocrinology from the University of the Philippines Philippine General Hospital (UP-PGH). Despite the indication for HRT, not everyone is able to afford the treatment. In 2011, a total of 483 women who consulted for menopause at [UP-PGH]. There were only 21 patients on the treatment, said Esguerra Resolving conflicts of evidence in hormone replacement Diana was then advised hormone replacement therapy. She was told by her relatives in the United States that hormone replacement could cause a variety of ailments, from ovarian malignancy and
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Individualizing hormonal therapy After weighing the risks and benefits of HRT, Diana is more amenable to the treatment. She reports that an internet search has revealed many kinds of HRT, and inquires which one is best for her. Unlike most guidelines, the IMS does not recommend specific types of HRT, nor does it pose a specific dose and regimen. HRT should be customized and individualized when administered. There have been only a few studies that have shown the superiority of one form of HRT over another. The most common regimen used is therapy combining estradiol hemihydrate 2mg and drosperinone 1mg. Another common regimen used is conjugated equine estrogen at 0.625mg/tab, said Esguerra. Since the main goal of HRT in menopause is to relieve symptoms brought about by estrogen loss, HRT should be given only to symptomatic patients. It should be started early in menopause. Initiating treatment in patients beyond 60 years of age and in patients who have suspected or known cardiovascular disease is not recommended. The duration of treatment should last as long as the patient experiences symptomatic relief. Annual health checks with a thorough physical examination and focused laboratory work-up serve to assess cardiovascular risk. There is no clinically proven superior form of HRT. However, progesterone should be added to systemic estrogen in all women with a uterus in order to prevent endometrial hyperplasia and cancer. The exception to the progesterone rule is the use of low-dose vaginal estrogen, where the level of hormone is too low to stimulate the endometrium. Progesterone lowering is also necessary to
breast cancer to heart attack and stroke. She asks her physician if the benefits of hormone therapy outweigh the risks. In 2002, a landmark series of studies, the Womens Health Initiative (WHI), analyzed cardiovascular risk of women, including women in menopause. It found an excess number of cardiovascular deaths among older women receiving hormone replacement. Other trials, such as the Million Women Study in the United Kingdom, have also found increases in stroke, breast cancer, and endometrial bleeding. The progesterone component of HRT has even been linked to an increase in breast cancer. These multiple complications have led many patients and doctors to refrain from utilizing hormone replacement therapy. In order to address these concerns, a systematic review was performed by Harman and colleagues on the effect of HRT and cardiovascular events. The results were published in the American Journal of Medicine in March 2011. It discovered that the increase in coronary disease risk was confined to more remotely menopausal or older women. The average of the population in WHI was 63 years. In the Nurses Health Study, where the average age was 51 years, women who started HRT at or near menopause had significant coronary heart disease protection compared to those who started later. This set the foundation for the timing hypothesis. Practitioners in the Philippines refer to the Clinical Practice Guidelines on Menopause, published in 2009. However, a decade since the release of the WHI, the International Menopause Society (IMS) has taken into consideration evidence that has come to light.
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Philippine Focus
consumption (no more than 1 alcohol unit a day) are necessary. These improve cardiovascular health and decrease the risk for cancer. Hormone replacement and healthy aging A few months after initiating HRT and making significant lifestyle changes, Diana reports feeling in excellent health. She follows up regularly with her reproductive endocrinologist for adjustment of her hormone therapy. Shes keen on completing a 42-kilometer marathon with her husband, and is currently training for it. Hormone replacement therapy indeed introduces a plethora of benefits to menopausal women that would help increase their quality of life. With a wholistic, individualized approach to the use of HRT, menopause need not be feared, but faced with the dignity and comfort of healthy aging.
*Subjects last name withheld for privacy REFERENCES Manson JE, Hsia J, Johnson KC, Rossouw JE, Assaf AR, Lasser NL, Trevisan M, Black HR, Heckbert SR, Detrano R, Strickland OL, Wong ND, Crouse JR, Stein E, Cushman M; 2003 Womens Health Initiative Investigators. Estrogen plus progestin and the risk of coronary heart disease. N Engl J Med 349:523534. Beral V, Reeves G, Bull D, Green J; for the Million Women Study Collaborators. Breast cancer risk in relation to the interval between menopause and starting hormone therapy. J Natl Cancer Inst. 2011 Jan 28. Harman SM, Vittinghoff E, Brinton EA, Budoff MJ, Cedars MI, Lobo RA, Merriam GR, Miller VM, Naftolin F, Pal L, Santoro N, Taylor HS and Black DM. Timing and duration of menopausal hormone treatment may affect cardiovascular outcomes. Am J Med. 2011 March; 124(3): 199205. Stampfer MJ, Colditz GA, Willett WC, et al. Postmenopausal estrogen therapy and cardiovascular disease. Ten-year follow-up from the Nurses Health Study. N Engl J Med. 1991; 325:756762. Sturdee DW and Pines A on behalf of the International Menopause Society Writing Group. Updated IMS recommendations on postmenopausal hormone therapy and preventive strategies for midlife health. Climacteric 2011;14:302320.
decrease the risk for breast cancer. Thus, the patients HRT should be titrated so the lowest effective dose is achieved. The specific route of administration in HRT should be dictated by the patients clinical profile and preferences. For instance, in patients with an increased risk of stroke or venous thromboembolism, transdermal estrogen may be utilized in order to avoid the first-pass effect in the liver and decrease these risks. Androgen insufficiency may also manifest in women with menopause. These women have decreased libido, lowered mood and a diminished sense of well-being. To improve the quality of life, testosterone may also be administered. Wholistic approach to health during menopause The IMS recommends that HRT is only part of the wholistic approach to menopausal health. A cardiovascular diet is prescribed, comprised of multiple daily servings of fruits, vegetables, and whole grain fiber. At least 2 servings of fish a week is recommended. Total fat should be low, with the exception of olive oil, which was proven to decrease cardiovascular risk. Weight loss is also crucial in preventing the occurrence of cardiovascular events. Studies have demonstrated that 5 to 10% loss of body weight already results in significant cardiovascular risk reduction. For menopausal women, exercise should be performed for at least 150 minutes/week. No specific exercise is recommended. The type and intensity should be tailored to the patients aerobic fitness, with care to prevent injury. Smoking cessation and reduced alcohol
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Philippine Focus
BEYOND THE CLINIC
The physician as a landscape artist and a hotelier

Dr. James Salisi
arangani Highlands Hotel sits on a hill overlooking Sarangani bay. Co-owned and managed by Dr. Tranquilino Ruiz, the hotel started out as a garden that evolved into a restaurant with a spectacular view of the largest bay in the Philippines; and later on it expanded into a 21-room hotel with function rooms. In 2007, Ruiz, in partnership with Dr. Anabel Abella and a business partner from Manila, acquired a piece of land in General Santos, 300 feet above sea level. They started designing landscapes and people started coming in; eventually, these frequent visitors asked them to put up a restaurant. When business picked up, they expanded and put up a hotel now called Sarangani Highlands. It is named after the bay, Sarangani Bay, Sarang ani which is an Indonesian phrase for this is our territory, said Ruiz. As operations manager, he spends most of his time running the business, taking care of the restaurant and the hotel as well as the maintenance of the landscape of the resort. What started out as a hobby evolved into a business. Ruiz would do landscaping on the side and even attended workshops to know more. He did Manny Pacquiaos house, commercial spaces like hotel and sports center, and other doctors houses in General Santos. He also acted as a consultant in the design of Plaza General in General Santos as well as for
the General Santos City Airport. Because people know that he is a doctor (he introduces himself as one), the perception about their place is improved especially with regard to cleanliness. Being a doctor is an advantage when you go into business. Loans from banks are easier to get, he said. Ruiz is a direct descendant of the first colony supervisor of Agricultural Colony Number 9, Don Tranquilino Ruiz, who was appointed by Governor Francis Burton Harrison. Ruiz has a degree in Commerce and secretly took science courses in preparation for medicine, not law, which his father wanted him to take. After obtaining his medical degree from Southwestern University Matias H. Aznar College of Medicine, he worked as resident physician in Bohol for 10 years. He went back to Glan and established a clinic. Since he comes from a political family, he started engaging with the community in the
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Philippine Focus
Ruiz is keen on promoting tourism because he believes that it creates jobs for the people especially in Glan, Sarangani, which has pristine white-sand beaches and an expansive view of Sarangani bay that regularly attract tourists from neighboring General Santos City and the rest of southern Mindanao. We should always provide people with jobs. Kapag may trabaho ang tao, they will not ask for dole out from the politicians, he said. His eye for landscape design has helped him create a unique environment for Sarangani Highlands Hotel. Well-tended flower gardens and trees that surround the hotel provide a romantic backdrop for weddings while the bonsai trees from his fellow physicians, wooded pathways, and fountains lend a tranquil vibe that easily relaxes the mind. But more than the spectacular view and the privilege of shaping an aesthe-tically pleasing space for visitors in General Santos City, what he likes about the Sarangani Highlands is that he gets to meet a lot of people. The hotel and its gardens are his sanctuary from the stresses of being a physician-on-call and a public servant.
early 90s by promoting tourism in Glan. He converted their ancestral house into a gallery of memorabilia from the early days of Glan. Open to the public for viewing, his art collection and family heirlooms told the history of the Ruiz family and the history of Glan.
We should always provide people with jobs. 2 15-30 April 2012 Regiona l Kapag may trabaho ang tao, they will not ask for dole out from the politicians
He eventually ran for public office in the last elections and won a seat in the town council. Because of his experience as a doctor and as part of the hospitality industry, he has been selected to head the committees on tourism, health and social services. His work in the tourism industry started in 1994 when he spearheaded activities related to it. For example, he inspired the indigenous people like the Blaan to engage the younger generations of their tribe to continue their weaving tradition and basketry.
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Philippine Focus
NOTES ON LEADERSHIP
The Medical Tribunes Dr. Yves Saint James Aquino talks to presidents of specialty societies to discuss their roles in promoting their respective fields
Leading the way for the educated patient

Photo courtesy of NGP Integrated Marketing Communications
early practice years, because we feel that, really, the future of the specialty of endocrinology is based on these young trainees. They are the lifeline of the society. To further strengthen the training of the fellows, PSEM has collaborated with local and international societies, especially in doing more research, Jasul shared. The Philippines is slowly gaining its leadership role in the region. Even for research, many drug trials, new drugs that are not yet in the market, are being tested in the Philippines. So, there are many endocrinologists as well as other specialists who are now involved in drug trials. Thats a positive development because it means were able to participate in international undertakings, he explained. According to Jasul, these kinds of research would help improve the way specialists manage their patients. However, he emphasized that the real challenge is increasing patients awareness of the fact that most of the noncommunicable diseases handled by the specialty (eg, diabetes, obesity), are actually preventable. Many of our projects right now are really focused on disease prevention, Jasul said. These diseases are not only problems in endocrinology, but are considered public health concerns as well. We need to have concrete and multi-disciplinary approach to the prob-
Dr. Gabriel Jasul Immediate Past President Philippine Society of Endocrinology and Metabolism fulfilling aspect in leading one of the oldest specialty societies in the Philippines was being able to recommend changes to improve medical training and practices, said Dr. Gabriel Jasul, immediate past president of the Philippine Society of Endocrinology and Metabolism (PSEM). One of the thrusts of PSEM ... is a strong emphasis on training of future endocrinologists, explained Jasul, who holds his clinic at St. Lukes Medical Center in Quezon City. We try to really watch how we start our trainees from their training years up to their
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Philippine Focus
Trainors workshops. Various topics on diabetes are discussed by PSEM volunteers, with a short question and answer portion to extend diabetes education to more patients. PSEM has also prepared e-modules, or digital aids containing educational information on diabetes, through the National Telehealth Center of the University of the PhilippinesManila, to reach health workers in far-flung areas. Lay fora on other conditions such as thyroid diseases, cholesterol problems, osteoporosis and obesity are regularly conducted by PSEM in different parts of the country. According to Jasul, whenever they hold weekend courses for medical professionals and health volunteers, they do simultaneous lay fora for the patients and their families. In a year, at least four weekend courses are conducted by the society, with each course covering one of the four major topics that include general endocrinology, diabetes, lipid imbalances and thyroid problems. Being active with the advocacy program is the kind of mark that Jasul wanted to leave during his term, and one of the thrusts that PSEM is hoping to continue. I think the best patient really is the educated patient, he said. Compliance is always a big problem in many chronic diseases, and we are dealing with not only diabetes, but also thyroid disease, obesity. So, to be able to get the patient to cooperate and to comply, you really need to make sure that they are well-educated about their disease, Jasul concluded.
lem. Otherwise the problem will be worse 50 years from now. A number of advocacy programs by PSEM are geared towards awareness campaigns, which are done through training of health workers, distribution of educational materials and lay workshops. These programs are usually done in partnership with government agencies, non-governmental organizations, private companies and other specialty societies. PSEM initiated the Hawak Kamay Laban sa Diabetes Train-the-Trainors workshops to train barangay health workers (BHW), which help these health volunteers understand diabetes, even improving their skills on how to prevent it and how to screen patients. Trainthe-Trainors courses were held in Manila and Laoag, involving hundreds of BHWs.
We need to have
concrete and multi-
disciplinary approach to the problem. Otherwise the problem will be worse 50 years from now.
The Hawak Kamay Diabetes Academy on Air, in collaboration with DZMM Teleradyo, ABS-CBN Foundation and Merck Sharp and Dohme (MSD), is a weekly 15-minute radio program with the same objective of diabetes awareness and prevention as the Train-the-
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Philippine Focus
NOTES ON LEADERSHIP
The Medical Tribunes Dr. Yves Saint James Aquino talks to presidents of specialty societies to discuss their roles in promoting their respective fields
A young specialty gains more ground

a relatively young field in the Philippines that started in the late 1980s. And even much younger is the fields specialty society, PCEM. Only three years ago, in 2009, that the two separate emergency medicine societiesthe Philippine College of Emergency Medicine and Acute Care (PCEMAC) and the Philippine Society of Emergency Care Physicians (PSECP)merged to form a unified college, according to Lagman, who practices at Makati Medical Center. Within a few years, PCEM was able to standardize its by-laws, establish a board to oversee specialty training and set up annual conventions, while balancing the interest of the two original groups. To further enhance local practice, PCEM intends to become part of regional and international societies for emergency medicine, which would give EM doctors the opportunity to attend larger conferences and conventions. It would give us more learning. More studies and more understanding on how EM should work, especially in the Philippines. There are lot of new technologies that we dont have yet, said Lagman. As a relatively young field, Lagman admitted that the society is facing serious challenges. And one of them is dealing with patients. The concept of what an emergency is, [this] is not yet really understood by all the
Dr. Noel Lagman Outgoing President Philippine College of Emergency Medicine
ention emergency medicine, and one inevitably thinks of a chaotic and almost cinematic picture in emergency rooms, much like the American TV series appropriately entitled ER. Well, when we get trauma patients, stab wounds, gunshot wounds, its almost similar. Minus the drama. But we also have our own little drama in (our own) ER, admitted Dr. Noel Lagman, outgoing president of the Philippine College of Emergency Medicine (PCEM). Considered as one of the most exhilarating practices, emergency medicine or EM is
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Philippine Focus
training (institutions) in their provinces, said Lagman. The exhilarating, fast-paced practice of emergency care is the typical reason why doctors enter the specialty, but for Lagman, who originally wanted to become a surgeon like his father, the reason was more personal. When my father got sick ... he had a cardiorespiratory arrest at home, and I had to resuscitate him there in the garage and bring him to the hospital, Lagman shared. With only interns and no resident or consultant meeting them at the ER, he ended up performing CPR on and intubating his own father. The passion that he discovered 16 years ago still remains, he said, especially when he encounters challenging cases such as acute MI, gunshot wounds and other types of trauma patients. You have to think fast. You have to decide fast when to refer, and when to bring the patient up to the OR. Thats the most exciting thing about emergency medicine, Lagman shared.
people. When the Filipino people think that, for example, when they have fever for only a few hours, they think that its an emergency and that they really have to go to the ER, said Lagman. It is important for Filipinos to understand that EM doctors need to prioritize which patients should be seen first, he added. But the problem is not just the patients, even colleagues in the profession is a challenge.
The concept of what an yet really understood by all the people.
emergency is, [this] is not
Because its fairly new, some other doctors, especially the old doctors, really dont understand what emergency medicine is. They think that were trying to get into their practice, but were not, clarified Lagman. He explained that the practice of EM doctors remain within the confines of the ER. Clinical practice guidelines are being developed in order to know where to end our practice and when to refer to other doctors. ... We will have to refer the patients back to them, of course. Besides the older generation of doctors, the society also has to deal with pursuing the younger generation to have more medical graduates enter the specialty. Most of the accredited training institutions are in Metro Manila, and PCEM is planning to expand accreditation to include hospitals in other provinces. Were training doctors from the provinces and then sending them back to open up those
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MARKET WATCH
Unilabs LRI and Therapharma merge
RI and Therapharma, two of the biggest divisions of United Laboratories, announced their official merging last February 21, 2012, in the presence of luminaries from the medical community. LRI-Therapharmas combined experience in cardiovascular and metabolic treatments paved the way to the companys Triumvirate of Stroke Management, which includes Plogrel (Clopidogrel bisulfate), Trombocil (Cilostazol) and Aspilet (Aspirin). Plogrel is indicated for the prevention of atherosclerotic events in patients with history of recent myocardial infarction (within a few days until <35 days from occurrence), recent ischemic stroke (from 7 days until <6 months) or established peripheral arterial disease. Trombocil is indicated for the treatment of ischemic symptoms eg ulcer, pain and coldness of extremities in chronic arterial occlusion. Also for prevention of recurrence of cerebral infarction except cardiogenic cerebral embolism. Aspilet is indicated for suspected acute MI, and for prophylactic treatment of thromboembolic disorders, MI, transient ischemic attacks and stroke.
Pfizer launches pneumococcal vaccine for adults

fizer Inc. has officially launched in the Philippines its vaccine for adults aged 50 years old and above against pneumonia, the leading cause of morbidity and the fifth leading cause of mortality in our country. Filipinos aged 50 years old and above account for 88 percent of deaths due to pneumonia.
Representatives from Pfizer during the launch
Often, pneumococcal disease attacks individuals with compromised immune systems and these are usually adults who are already suffering from other conditions, said Dr. Rontgene Solante, president of the Philippine Society of Microbiology and Infectious Diseases. The pneumococcal vaccine of Pfizer has been available in the country since 2010 for use in children ages 2 to 5 years old and is now approved for adults 50 years old and above in the Philippines since November 2011. The adult indication was approved by the European Medicines Agency last October 2011 and the US Food and Drug Administration last December 2011.
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MARKET WATCH
MSD promotes better diabetes management with breakthrough medicine

erck Sharp & Dohme (MSD), a global healthcare leader that provides medicines, vaccines, biologic therapies and consumer care products, promoted better management of diabetes by discussing dipeptidyl peptidase-4 inhibitors, one of the latest drugs for diabetes. One of guest speakers, Dr. Daniel Drucker, senior scientist with Samuel Lunenfeld Research Institute in Mt. Sinai Hospital, Toronto, discussed the science behind DPP-4, as well as its efficacy and safety profile. Dr. Daniel Drucker Drucker has been involved in studies on incretin-based therapies, to which DPP-4 inhibitors belong, that are now widely used for the treatment of type 2 diabetes. For the first time in the management of diabetes, we are able to use medications that do not produce hypoglycemia or a low blood sugar as a side-effect, and do not cause weight-gain, said Drucker. Drucker also explained that the new drugs are the easiest drugs to prescribe. They can be taken once a day, and there are once weekly versions in development, he said.
Invida introduces new anti-aging skin care range
nvida recently launched the Kinerase Skin Care System, which utilizes kinetin, a potent bio-growth factor derived from plants. The skin care line was developed by Canada-based Valeant Pharmaceuticals, a multinational specialty company. Our almost three decades of research has shown that kinetin exerts powerful effects in delaying several signs of skin aging, said Prof. Suresh Rattan, a noted biogerontologist, during the media launch held last March 2012 in Bonifacia Global City, Taguig. Rattan, currently the head of the Laboratory of Cellular Aging, Depart-ment of Molecular biology, Aarhus University, Denmark, is considered the Father of Kinetin as he holds the sole inventorship for discovering the anti-aging effects of kinetin in human skin cells. We are pleased to make the Kinerase Skin Care System available to Filipino dermatologists and their patients, said Dr. Maaliddin Biruar, medical and scientific affairs director of Invida Philippines.
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MARKET WATCH
Aspen brings quality, affordable drugs to the Philippines
spen, Africas largest pharmaceutical manufacturer, opened its local subsidiary in the Philippines, aiming to make high-quality branded medicines available to Filipino patients at affordable cost. We take great pride in formally opening our office in the Philippines. This business initiative forms part of Aspens state global expansion strategy into emerging and established markets, and we look forward to working closely with the Philippine government and local regulatory bodies in providing quality products to meet the healthcare needs of the Filipino people, said Mr. Stephen Saad, Aspen Group Chief Executive. Aspen has 18 manufacturing facilities in 13 pharmaceutical manufacturing sites on six continents. Four of the sites are located in Sout Africa, four in Australia, and one each in Kenya, Tanzania, Brazil, Mexico and Germany. Aspen Philippines commenced operations in January 2012 with only four employees, but after two months, the staff complement has increased to nearly 100 Filipinos. We are honored and grateful that Aspen chose to establish its first Asian subsidiary in the Philippines. Our partnership with a global pharmaceutical leader not only makes medicines of superior quality with prices that are within means available to Filipino patients, it also provides employment to local talents, said Ms. Ace Itchon, President and CEO of Aspen Philippines, Inc.
Insulin for Life awarded during PSEM convention

li Lilly and Company and the Philippine Society of Endocrinology and Metabolism (PSEM) awarded insulin medication for life to selected recipients during the societys annual convention held in EDSA Shangri-La Hotel. Patients that are eligible for medical support must be Filipino citizens, have no private or public prescription coverPhoto shows (from left) Dr. Levy Jasul, PSEM immediate past president; age, and must be earning an Dr. Rosa Allyn Sy, project chair of Insulin for life; recipeint Cecilia Dela Queva; and Dr. Cecille Aonuevo-Cruz. amount within the program guidelines. Patients must be nominated by a PSEM member. Insulin vials and syringes will be delivered or dispensed directly to patients by their physicians.
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News
Bergamot orange a natural supplement for cholesterol control

Rajesh Kumar
An Australian cardiologist has found a natural ally in his fight against metabolic disorders an extract of the bergamot orange, an Italian citrus fruit which has long been believed to possess heart health benefits. Dr. Ross Walker, who runs a private practice in Sydney, said he has successfully used the extract in about 700 of his registered patients who are overweight with dyslipidemia and elevated blood sugar levels. Within a few weeks of starting the supplement, some of those patients have totally avoided the need for statins while others have reduced their statin dose to control dyslipidemia. As a bonus outcome, their blood glucose and middle obesity have also significantly reduced, said Walker. His findings are consistent with those of an unpublished clinical study conducted in Italy involving more than 200 patients with hyperlipidemia. In the study, 1 months supplementation with bergamot reduced LDL cholesterol by 39 percent and blood sugar by 22 percent, and raised HDL cholesterol by 41 percent. Bergamot contains extremely large amounts of polyphenols, as compared to other citrus species. Two of these, Brutelidin and Metilidin, directly inhibit cholesterol biosynthesis in a similar way to statins and they are not found in any other citrus derivatives, said lead study author Dr. Vincenzo Mollace, professor in the faculty of pharmacology at the University of Cantanzaro in Italy. Bergamot extract blocks the HMG CoA reductase enzyme at a different level than statins. As a result, myalgia and other side effects typically associated with statins can be avoided because bergamot does not block the component that depletes the muscular co-enzyme q10, said Walker. Bergamot extract (BergametTM) also inhibits cholesterol absorption in the gut, the same way plant sterols do. Thats why I ask my patients to take it 15 minutes before meal twice a day, in the afternoons and evenings, to block cholesterol absorption from food, he said. The unique and most important action of bergamot, due to which cardiologists (like me) are supporting this, is that it affects metabolic syndrome as a whole: raising HDL cholesterol, lowering LDL and blood sugar and reducing arterial stiffness and middle obesity. Could patients be advised to consume bergamot juice as part of a healthy diet to prevent metabolic syndrome, rather than taking its extract in a pill form? Walker said it is not that easy since bergamot orange is extremely bitter/sour and large amounts of its juice would be needed to get the desired benefit. [Bergamot extract] is not a replacement for statins. Patients who have had a heart attack or have vascular disease do need to take statins. [But] the extract can be useful in preventing metabolic syndrome, correcting it in early stages and as a supplement to reduce statin dose, he said.
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News
Omega-3 fatty acids help slow aging of the brain

Rajesh Kumar
he status of omega-3 fatty acids as brain food is well established. However, research now suggests a diet lacking in these fatty acids may cause brain to age faster and lose some of its memory and thinking abilities. The finding has prompted a study author to recommend that physicians should remind patients to regularly consume fatty fish or other food sources of omega-3 as part of a balanced diet. [In the study] people with lower blood levels of omega-3 fatty acids had lower brain volumes that were equivalent to about 2 years of structural brain aging, said lead researcher Dr. Zaldy Tan of the Easton Center for Alzheimers disease research and the division of geriatrics at the University of California at Los Angeles, California, US. A total of 1,575 people with an average age of 67 and free of dementia underwent MRI brain scans for the study. They were also given tests that measured mental function, body mass and omega-3 fatty acid (comprising docosahexaenoic acid or DHA, and eicosapentaenoic acid, EPA) levels in their red blood cells. [Neurology 2012;78: 658-664]. Fatty acid composition of red blood cells (RBC) reflects dietary fatty acid intake averaged over the RBC lifespan of up to 120 days, whereas plasma concentrations reflect intake over only the last few days. The researchers found that people whose
The regular consumption of fatty fish or other food sources of omega-3 fatty acids is well known to be part of a balanced diet.
DHA levels were among the bottom 25 percent of the participants had lower brain volume compared to people who had higher DHA levels. Similarly, participants with levels of all omega-3 fatty acids in the bottom 25 percent also scored lower on tests of visual memory and executive function, such as problem solving and multi-tasking and abstract thinking. Lower DHA levels are associated with smaller brain volumes and a vascular pattern of cognitive impairment, even in persons free of clinical dementia, concluded the researchers. It may be premature for physicians to advise their patients to consume adequate amounts of food rich in omega-3 specifically for their brain health, without evidence from a large randomized control trial. But Tan said there is already ample evidence supporting the benefits of this fatty acid in cardiovascular and overall health and such an advice could only be beneficial.
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News
Even mild hearing loss increases risk of falling

Rajesh Kumar
dults aged 60 and older should be routinely screened for hearing loss and treated according to best practice guidelines, according to Dr. Frank Lin, assistant professor of otolaryngology at the Johns Hopkins University School of Medicine and Bloomberg School of Public Health in Baltimore, Maryland, US. The advice follows research findings that link even mild hearing loss to a three-fold risk of falls. Hearing loss among the elderly is already associated with a range of social and cognitive problems, including dementia. But the researchers feel the latest finding could help in the development of new ways to prevent falls and resulting injuries that cost billions of dollars in health care. We still do not know if treating hearing loss can reduce falls. But hearing loss treatment entails no risks and could potentially only lead to benefits for cognitive, social and physical functioning, said Lin, adding that hearing loss was only one of many potential risk factors for falls. To determine whether hearing loss and falling are connected, Lin and colleagues used data from the 2001 to 2004 cycles of the US National Health and Nutrition Examination Survey. A total of 2,017 participants aged 40 to 69 had their hearing tested and answered questions about whether they had fallen over the past year. [Arch Intern Med 2012;172:369371] They also collected demographic information, including age, sex and race, and tested
participants vestibular function, a measure of how well they kept their balance. They found that people with a 25-decibel hearing loss, classified as mild, were nearly three times more likely to have a history of falling. Every additional 10-decibels of hearing loss increased the chances of falling by 1.4 fold (95% CI, 1.3-1.5).
Gait and balance are ... actually very cognitively demanding
The finding held true even when researchers accounted for other factors linked with falling, including age, sex, race, cardiovascular disease and vestibular function. Excluding participants with moderate to severe hearing loss from the analysis also didnt change the results. Among the possible explanations for the link is that people who cant hear well might not have good awareness of their overall environment, making tripping and falling more likely, said Lin. Another reason hearing loss might increase the risk of falls is cognitive load, in which the brain is overwhelmed with demands on its limited resources. Gait and balance are things most people take for granted, but they are actually very cognitively demanding. If hearing loss imposes a cognitive load, there may be fewer cognitive resources to help with maintaining balance and gait, he said.
34 Industry Update
Role of heart rate, sympathetic activity in CVD
Compelling evidence from experimental and clinical studies links elevated heart rate with higher risk of cardiovascular events in patients with coronary artery disease and chronic heart failure. At a recent cardiology symposium sponsored by Merck Serono, three experts discussed the role of heart rate and sympathetic activity in the development of CVD as well as the sympatho-inhibitory and cardioprotective effects of selective beta-blockers, in particular bisoprolol (Concor). The cardiovascular continuum The cardiovascular disease (CVD) continuum frames CVD as a chain of events initiated by a number of risk factors leading to the end stage of the disease. [Circulation 2006;114:2850-2870]. It continues as a pathophysiologic process lasting for decades. It is essential that cardioprotection at each stage is provided to the patient. Hypertension is one of the earliest and most important risk factors in the CV continuum and its effective control is now recognized as a prerequisite for strategies for the prevention of stroke, coronary events and heart failure. Adrenergic neural factors may participate in the development and progression of the hypertensive state and its complications. This represents the rationale for the use of antihypertensive drugs with sympatho-inhibitory effects. [Am J Hypertension 2010; 23:1052-1060] Elevated heart rate as a risk factor The association between resting heart rate (HR) and mortality has been observed in patients with hypertension. Sympathetic over-activity also participates in the genesis of major complications of hypertension, such as congestive heart failure (CHF), ischemic coronary events, major cardiac arrhythmias and sudden death. [Hypertension 2009;54:690-697] More recently, the prognostic value of resting HR has also been demonstrated in patients with coronary artery disease.
Dr. Yan
Prof Grassi
Dr. Ponikowski
Figure 1. Cardiovascular mortality according to heart rate in patients with LVH.

10
Heart rate 84 Heart rate <84
% with event
8 6 4 2 0 0 Number of risk
Heart rate 84 1873 1187 Heart rate <84 7315 7921
12
24
Month
36
48
60
960 8083
965 7919
931 7768
890 7629
367 3225
Figure 2. Comparison of sudden death rates in CHF patients receiving rst-line monotherapy with bisoprolol or enalapril in the CIBIS III trial.
5 Bisoprolol-rst vs enalapril-rst: 8 versus 16 sudden deaths; HR 0.50; 95% CI 0.21-1.16; P=0.107 1.6% ARR
Enalapril-rst
% pts
Bisoprolol-rst
0 0
505 505
1
488 493
2
467 476
3
454 460
4
444 450
5
430 444
6
251 232
Time (months)
Several observational studies, registries, and trials have identified HR as a risk marker for cardiovascular mortality, independent of other risk markers, including currently validated risk factors. [Eur Heart J Suppl 2008;10:F2-F6]
35 Industry Update
Consequently, HR is included in some risk assessment models for patients after acute coronary syndrome or post-myocardial infarction (MI). [Eur Heart J Suppl 2008;10:F11-F16; J Am Coll Cardiol 2009;54:1154-61] ta-blockers suggest that the beneficial effect of these agents in reducing total mortality and sudden cardiac death after MI is proportionally related to their ability to reduce resting HR.
If HR is a risk factor for hypertension, it would follow that reduction in HR would improve clinical outcomes
Dr. Peter Yan Cardiologist at Peter Yan Cardiology Clinic, Gleneagles Medical Centre, Singapore
An ideal CV drug should possess sympathomodulatory and cardioprotective properties

Professor Guido Grassi Professor of internal medicine in the department of clinical medicine at San Gerardo Hospital, Universita Milano Becocca, Milan, Italy
A study by Okin et al. showed that every 10 bpm higher HR on in-treatment ECGs in hypertensive patients was associated with a 16 percent increase in adjusted risk of CV mortality and with persistence or development of a HR 84 was associated with a 55 percent greater risk of CV death. (Figure 1). [Eur Heart J 2010;31:22712279] In terms of all-cause mortality, increments of 10 bpm in this sample of patients was associated with a 25 percent greater risk, while HR 84 persistence or development was associated with a 79 percent greater adjusted risk. Sympathetic over-activity represents a hallmark of the hypertensive state. Pronounced influence of the autonomic imbalance on cardiovascular morbidity and mortality is not simply a function of hemodynamic effects. Recent studies have revealed that a major determinant of the pathological process results from autonomic dysregulation of the inflammatory/immune system. [Hypertension 2012;59:755-762] Role of beta-blockers in CVD There is strong evidence to support the theory that beta-blockers positively interfere with neuroadrenergic function. Analyses of randomized clinical trials of be-
A statistically significant relationship was found between resting HR reduction and reduction in cardiac deaths and nonfatal MI recurrence. [Eur Heart J 2007;28:3012-3019; Am J Cardiol 2008;101:865-869] Therefore, beta-blockers may play an important role in HR reduction in the CVD continuum. HR reducing effects of bisoprolol Cardiac events are the leading cause of late morbidity and mortality after successful major vascular surgery. After peripheral bypass surgery, for example, 3-year mortality is approximately 30-40 percent.
There is no doubt that HR reduction is closely linked with improvement in mortality
Dr. Piotr Ponikowski Medical University, Centre for Heart Disease, Clinical Military Hospital, Wroclow, Poland
Peri-operative and long-term post-operative bisoprolol administration produces a 3-fold reduction in late cardiac death and MI rates among high-risk patients after successful major noncardiac vascular surgery.
36 Industry Update
The results of the CIBIS (Cardiac Insufficiency Bisoprolol) II trial showed that patients with heart failure in sinus rhythm with the initial lowest HR and the greatest HR reduction with time (2 months) will have the best prognosis. Betablockade with bisoprolol further improves survival at any level of basal HR to a similar extent. [Circulation 2001;103:1428-1433] When bisoprolol, carvedilol and nebivolol were compared directly, HR at exercise was decreased at 3 hours following intake of the first single dose of each drug by bisoprolol (-24 percent), carvedilol (-17 percent) and nebivolol (-15 percent). [Cardiology 2006;106:199-206] The results of the CIBIS-ELD (in elderly) study showed that the selective 1-adrenoceptorblocker bisoprolol was associated with a greater reduction in HR than carvedilol. [Eur J Heart Fail 2011;13:670-680] In comparison with other antihypertensive agents, bisoprolol frequently proved to be more effective or better tolerated. [J Cardiovasc Pharmacol 1986; 8:S122-127] Bisoprolol in congestive heart failure Sudden death is the most prevalent cause of death in the early course of CHF. When bisoprolol was compared to enalapril (CIBIS III trial) bisoprolol was found to be non-inferior to enalapril and at least as important as ACE inhibitors in patients with CHF (Figure 2). [Eur Heart J 2006; 8: C43-C50] A bisoprolol-first strategy reduced mortality by 31 percent, compared with an enalapril-first strategy. The results support bisoprolol as a first-line treatment for CHF. Recently, it was suggested that switching from carvedilol to bisoprolol may help with continuation of beta-blocker treatment as well as dosage increase in patients with heart failure who suffer adverse symptoms or signs, allowing them to reach the target dose. [J Am Coll Cardiol 2012;59:E885] Atrial fibrillation (AF) occurs frequently soon after coronary artery bypass grafting (CABG) and often results in increased mortality and morbidity, particularly in patients with heart failure. Bisoprolol is more effective than carvedilol in decreasing the incidence of post-discharge AF after CABG in patients with decreased left ventricular function. Greater effectiveness of bisoprolol could be related to its greater 1-receptor selectivity, imparting a greater degree of protection against increases in sympathetic activity. [Am J Cardiol 2011;107:215219] The pharmacokinetic properties of bisoprolol provide the prerequisite for a single daily dose and ensure an extremely low inter- and intra-individual variability of the plasma concentration profiles. [J Cardiovasc Pharmacol 1986; 8:S16-20] Conclusions It has been postulated that elevated heart rate may become a therapeutic target in CV diseases, particularly in coronary artery disease and chronic heart failure. Beta-blockers reduce morbidity, mortality, and improve functional status in CHF patients, thus remaining a cornerstone of the pharmacological management of CHF. Bisoprolol is a highly cardioselective -blocker. It is safe, effective, and well tolerated. Due to its high 1 selectivity and pharmacokinetic profile, it confers reliable 24-hour efficacy and cardioprotection.
37
May
May 2012
Calendar
19th WONCA Asia Pacific Regional Conference 24/5/2012 to 27/5/2012 Location: Jeju, Korea
Tel: (82) 2 566 6031 Email: admin@woncaap2012.org Website: www.woncaap2012.org
5th European Clinam Conference for Clinical Nanomedicine 7/5/2012 to 9/5/2012 Location: Basel, Switzerland
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2012 American Society of Clinical Oncology Annual Meeting 1/6/2012 to 5/6/2012 Location: Chicago, Illinois, US
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19th European Congress on Obesity 9/5/2012 to 12/5/2012 Location: Lyon, France

Info: European Association for the Study of Obesity Tel: (44) 20 8783 2256 Fax: (44) 20 89796700 Email: enquiries@easo.org Website: www.eco2012.org
American Thoracic Society International Conference 2012 18/5/2012 to 23/5/2012 Location: San Francisco, California, US
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American Society of Hypertension 19/5/2012 to 22/5/2012 Location: New York, New York, US
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15th International Congress of Infectious Diseases 13/6/2012 to 16/6/2012 Location: Bangkok, Thailand
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Digestive Diseases Week 2012 19/5/2012 to 22/5/2012 Location: San Diego, California, US
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15th World Congress of Pain Clinicians 27/6/2012 to 30/6/2012 Location: Granada, Spain Info: Kenes International Tel: (41) 22 908 0488 Fax: (41) 22 9069140 Email: wspc2012@kenes.com Website: www.kenes.com/wspc
38
May 2012
Calendar
Upcoming
17th World Congress on Heart Disease 2012 27/7/2012 to 30/7/2012 Location: Toronto, Ontario, Canada
Info: International Academy of Cardiology Tel: (1) 310 657 8777 Fax: (1) 310 659 4781 E-Mail: Klimedco@ucla.edu Website: www.cardiologyonline.com
European Society of Cardiology Congress 2012 25/8/2012 to 29/8/2012 Location: Munich, Germany
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May 2012

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