medical tribune december 2013

8/13/2019 Medical Tribune December 2013

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December 2013

www.mims.com

WHO shares new

strategy to end TB

Over-regulaon of

e-cigarees a potenal

threat to public health?

FORUM

Adult brain connues to

regenerate neurons

CONFERENCE

NEWS

IN PRACTICE

Treang hair loss

in women

BP lowering protects heart in early-

stage kidney disease


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2 December 2013

BP lowering protects heart in early-stage

kidney disease

Lianne Cowie

Lowering blood pressure is eective inpreventing cardiovascular events inpatients with mild or moderate kidney

disease, according to a large meta-analysis.Specically, blood pressure lowering

per se, not the eects of a particular drugclass... seems to be signicantly associatedwith lower cardiovascular risk in early-stage chronic kidney disease, possibly sug-gesting the importance of blood pressurelowering as a driver of cardiovascular riskreduction, said the authors of the report.

The Blood Pressure Lowering TreatmentTrialists Collaboration, a project funded bythe National Health and Medical ResearchCouncil of Australia, undertook a prospec-tive meta-analysis of 26 randomized trialsevaluating the ecacy of blood pressurelowering drugs against placebo, each oth-er, or specic blood pressure thresholds.All were required to have a minimum of1,000 patient-years of planned follow-up ineach randomized arm. The trials included152,290 individuals in total, 30,295 of whom

had a reduced estimated glomerular ltra-tion rate (eGFR)


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3 December 2013

Snoring in pregnancy a risk factor for

C-section, smaller babies

Rajesh Kumar

Pregnant women who snore three or

more nights a week have a higher risk

of poor delivery outcomes such as Ce-

sarean births and smaller babies, according to

the largest study of its kind.

Between March 2007 and December 2010,US researchers recruited 1,673 pregnant

women in their third trimester from prena-

tal clinics and followed them until delivery.

Women were screened for habitual snoring

as a known marker for sleep disordered

breathing. Outcome data were obtained

from medical records following delivery

and birth centiles were calculated. [Sleep

2013;36:1625-1632]A total of 35 percent women reported ha-

bitual snoring (26 percent with pregnancy-

onset snoring and 9 percent with chronic

snoring). Even aer accounting for other

risk factors, chronic snorers who snored be-

fore and during pregnancy were at the high-

est risks to have babies small for gestational

age (95% CI 1.02-2.66, p=0.041) and elective

C-sections (95% CI 1.22-4.18, p=0.008).More importantly, women who started

snoring only during pregnancy had a higher

risk of both elective and emergency C-sections

than women who did not snore. (95% CI 1.22-

2.30, p=0.001). An earlier study had linked

snoring during pregnancy with a high risk for

high blood pressure and preeclampsia.

[The ndings] suggest that we have a

window of opportunity to screen pregnant

women for breathing problems during sleep

that may put them at risk of poor delivery

outcomes, said lead author Dr. Louise

OBrien, associate professor at the Univer-

sity of Michigans Sleep Disorders Center in

the Department of Neurology and adjunct

associate professor in the Department of

Obstetrics & Gynecology at the U-M Medi-cal School in Ann Arbor, Michigan, US.

Screening pregnant women for symptoms

of sleep disordered breathing may provide

an early opportunity to identify women at

risk of poor delivery outcomes and treat

their obstructive sleep apnea using continu-

ous positive airway pressure (CPAP), the

researchers said.

Millions of healthcare dollars are spent on

operative deliveries, taking care of babies who

Pregnant women should be screened for breathing problems during theirsleep, according to new research.


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4 December 2013

are admied to the neonatal ICU and treating

secondary health problems that smaller babies

are at risk for when grown, OBrien added.

If we can identify risks during preg-

nancy that can be treated, we can reduce

the incidence of small babies, C-sections

and possibly neonatal ICU admissions that

not only improve long term health bene-

ts for newborns but also help keep costs

down.

READ JPOG ANYTIME, ANYWHERE.Downloadthe digital edition today at www.jpog.com


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5 December 2013 Forum

There has been much debate about the place of electronic nicotine delivery devices

(e-cigarees) in recent years, coincident with their ever increasing availability and popularity

across the world. Medicines agencies in the West have become increasingly concerned with

how to regulate these devices, which have the potential to act, and have been studied for their

eectiveness, as nicotine replacement therapies. Interestingly, while e-cigarees have their

supporters, not all are in favor of their regulation as medicines. Associate Professor Jean-

Franois Eer from the Faculty of Medicine, University of Geneva, Switzerland, provided thefollowing perspective, based on excerpts of his presentation at the recent E-Cigaree Summit

held in London, England.

Currently around the world, e-ciga-rees are mainly regulated as con-sumer products or tobacco products,

rather than medicines. However, impending

regulation amendments in Europe and the USare set to play a very important part in the fu-ture of these controversial products. Havingsaid this, there is no reason to expect that e-cigaree regulation will be the same in eachcountry. On the contrary, I think regulationswill dier between countries which take intolocal variations in factors such as stage of to-

bacco epidemic, history of tobacco regulation,political processes, weight of lobbies, and thestate of development of the e-cigaree mar-ket.

I believe that future e-cigaree regulationsin US and Europe will likely favor those whoare best at lobbying governments. And thiswill be detrimental to the smaller and mostinnovative players in this market the Chi-nese inventors and manufacturers. Big to-

bacco companies and big pharma will have

advantages they have so much expertiseworking within regulated environments.

They also have a lot of money, large and es-tablished customer bases, and existing shelfspace in shops. So they will be well placed tograb a large market share.

Currently in Europe, nicotine is regulatedin a way that I think is a disaster for publichealth. Throughout most of the continent, thecheapest and most deadly form of nicotine

in smoked tobacco is cheap and availableeverywhere, while smokeless nicotine is ei-

Over-regulation of e-cigarettes a potential

threat to public health?


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6 December 2013 Forum

ther banned or only available in medications(in patches or gums).

While nicotine replacement therapy (NRT)works, we know that dierences in long-term

quit rates between smokers given nicotinepatches or gums are only marginally beer (afew percentage points) compared with thosegiven placebo versions.

The success of e-cigarees is beginning tochallenge this approach and I think the reg-ulation of nicotine needs to be changed. Thequestion is how? Is it a good idea to regulatethe e-cigaree as a tobacco product and typi-

cally ban its use in public places, restrict ad-vertisements, sales, and use by minors, etc?E-cigarees are regulated as tobacco productsin some countries, even though they do notcontain tobacco. Nicotine is extracted from to-

bacco but does not contain tobacco. So its notvery logical.

There are several issues with placing strict-er controls on e-cigaree use. I think the ban-ning of e-cigaree vaping in public places,

for example, should require much strongerevidence that passive vaping is toxic or thatit encourages non-smokers to become vapersor smokers. Banning advertising, which helpsto inform consumers, is also a problematic is-sue.

One thing most people agree on howeveris that there should be restrictions for minors.However, even this is not straightforward

because minors who currently use nicotineor plan to use nicotine have no other choicebut to smoke in many countries. So providingthem an alternative way of geing nicotineis perhaps a controversial idea, but one thatshould not be rejected outright without fur-ther consideration.

I foresee several problems in regulating e-cigarees as medicines. Importantly, I thinkit will kill innovation. Take nicotine gum and

patches. They were invented in the 1970s and1980s and have almost not evolved since then.

Its not just the fault of the pharmaceuticalindustry but also the regulation frameworkwhich makes it so costly to improve a prod-uct. If such things as avors are banned for

example, then e-cigarees will become lessaractive. The other issue is what will hap-pen with all the unlicensed products? Theywill not miraculously disappear. Enforcementmay be very dicult, costly and ineective.Unlicensed products may end up on a blackmarket. Internet sales of unlicensed productswill continue for which there will be no man-datory quality control.

Other consequences of over-regulation willbe a trend towards fewer e-cigaree users,because of higher costs. Fewer smokers willtherefore quit and more will die. The entiree-cigaree market will become the domainof the tobacco industry because they are theonly ones with e-cigaree products almostready to be approved. I dont think this is adesirable outcome.

To conclude, I think e-cigarees are a ma-

jor innovation, a revolution in our eld, thathave the potential to save many lives. For reg-ulators, I think we should always keep in per-spective the huge number of deaths and dis-ease and misery caused by smoking tobacco.

The relative risk is relevant compared withcigarees because these products are used bysmokers. They dont need to be 100 percentsafe, only much safer than cigarees. Their

regulation as medicines or tobacco will bedisproportionate, and the prohibition of unli-censed products will not be feasible or desir-able.

The main danger for public health is theexcessive regulation of e-cigarees, not e-cig-arees themselves. Laws need to be changedto make room for safe recreational nicotineproducts, even if they are used compulsively,and this is one of the most important things

we have debated in public health in recent de-cades.


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7 December 2013 News

WHO shares new strategy to end TB

Dr. Yves Saint James Aquino

The End TB Strategy 2016-2035 aims

for a tuberculosis-free world by 2035

and is intended to immediately follow

the 2015 TB strategy and targets under the

Millennium Development Goals, shared Dr.

Tauhidul Islam, medical ocer with the Stop

TB Department of the World Health Organi-

zation-Western Pacic Region.Latest report from WHO has noted the es-

timated number of all forms of tuberculosis at

8.7 million and estimated number of deaths

due to TB at 1.4 million.

It means in a day, more than 3,000 patients

may die due to TB, and it means in one min-

ute, three people are dying, explained Islam.

And we know that TB is curable, so this situ-

ation is not acceptable.From data collected since 1990, the global

incidence rate peaked in 2000 and decreased

aer, with a fall of 2.2 percent per year from

2010 to 2011. Mortality rate is at 41-percent

decline since 1990, while prevalence rate is

at 36-percent decline. Both the incidence and

mortality rates are on track, but the preva-

lence rate is falling short of the development

goal.The End TB Strategy 2016-2035 is much

more ambitious having a target of 95-per-

cent reduction (compared with 2015 data) in

deaths and an incidence goal of less than 10

cases per 100,000 population, explained Is-

lam. There is also a mid-program goal of hav-

ing a 75-percent reduction in TB deaths and

less than 50 cases per 100,000 population by

2025.

According to Islam, despite the fact that 51

million patients are being cured and 20 mil-

lion lives have been saved since 1995, TB in-

cidence is still declining too slowly, with 1.4

million people still dying. He also stated that

response to multi-drug resistant TB (MDR-

TB) is slow and there are still gaps in nanc-

ing projects to ght the disease.Drug-resistant TB is a real challenge be-

cause the treatment duration is too long and

even aer treatment, the treatment outcome

is not really good enough, said Islam.

A quarter of the worldwide burden of

MDR-TB is seen in the Western Pacic Re-

gion, with more than 96 percent (79,000

cases) of that incidence shared by just three

countries that include China, Philippinesand Vietnam.

Islam explained that with the limitations

in funding, we must continue to prioritize

re-treatment cases and high-risk new cases

of MDR-TB. The government, apart from in-

creasing support for public health services,

should also engage the private sector in re-

porting cases, linking insurance coverage to

quality care and further optimizing public

service delivery.

The WHOs End TB Strategy 2016-2035 aims for a TB-free world by2035.


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ASEAN countries come together to fight

NCDs

Dr. James Salisi

Members of the Association of South-east Asian Nations (ASEAN) Bru-nei Darussalam, Cambodia, In-

donesia, Lao Peoples Democratic Republic,Malaysia, Myanmar, Philippines, Singapore,Thailand and Vietnam met in Manila, Phil-ippines on October 14 to 16, 2013 for the FirstASEAN Regional Forum on Non-Communi-cable Diseases (NCDs) hosted by the Philip-pines Department of Health (DOH).

DOH Secretary Enrique Ona highlighted inhis keynote speech the importance of the fo-rum in light of the coming ASEAN integrationin 2015. It is with great pleasure to share withyou that the development cause and concern

has reached the highest political level withinthe ASEAN Community. The need to addressNCDs has been constantly in the priority ofASEAN Health Cooperation, Ona said.

He further emphasized that the shi in theglobal health burden to NCDs as the leadingcauses of mortality, morbidity and disabilityin recent years has prompted governmentsaround the world to drive public health inter-

ventions towards curbing the risk factors forNCDs such as smoking and obesity.The ASEAN forum serves as a venue to dis-

cuss the challenges for NCD prevention andcontrol, promotion of health lifestyle, and shar-ing of best public health practices in the region.It was an opportunity for ministries of healthin the region to showcase policies, programsand activities and to learn from these and eachother.

The forum has developed a Work Plan onNCDs for 2011 to 2015 to ensure the accessi-

bility of adequate and aordable health care,medical services, medicines and promotion ofhealthy lifestyle for the ASEAN population.

The Philippines was chosen as the leadcountry in holding the rst ASEAN Forum onNCDs following our model and experience

in staging the multi-sectoral Public HealthConvention on the Prevention and Control ofNCDs conducted every 2 years, Ona said.

It was an opportunity for the DOH to show-case its policies, programs and activities onNCDs, particularly the Sin Tax Law, Philip-pine Package of Essential NCD Interventionsand the Pilipinas Go4Health Healthy LifestyleMovement. During the forum, the Outstand-

ing Healthy Lifestyle Advocacy Awards werealso given out to the exemplary work of localgovernment units, non-government organiza-tions, business establishments and academicinstitutions who advocated NCD preventionmeasures.

The Bandar Seri Begawan Declaration onNon-communicable Diseases in ASEAN waspresented at the end of the 3-day forum. Gov-ernment ocials, public health experts and no-

table healthy lifestyle champions and expertsacross the region participated in the forum.

Delegates of the rst ASEAN Forum on NCDs (Photo credit:

Philippines DOH)


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HRT needed for post-menopausal women

without frequent hot flashes?

Rajesh Kumar

Hormone replacement therapy (HRT)

may be of no use in improving the

quality of life of post-menopausal

women if they are not experiencing hot ash-

es, according to a study.

The researchers equally randomized 150recently menopausal women to HRT with

transdermal estradiol (1 mg/day), oral estra-

diol (2 mg/day) with or without medroxy-

progesterone acetate (5 mg/day), or placebo

for 6 months. Seventy-two women experi-

enced 7 moderate to severe hot ashes per

day, while the rest reported having 3 mild

hot ashes per day or none at all. [Menopause

2013; doi: 10.1097/gme.0000000000000120]In women with more hot ashes at base-

line, HRT use signicantly improved the

scores for sleep compared with placebo

(0.787 vs. 0.557, respectively, p=0.001), mem-

ory and concentration capacity (0.849 vs.

0.454, p


10/38


Higher dietary acid increases diabetes

risk in women

Rajesh Kumar

Higher dietary acid, regardless of the

individual foods making up that

diet, increases the risk of type 2 dia-

betes, according to a large study, the rst of

its kind, involving more than 60,000 women.

A diet rich in meat and other acidogenicfoods such as zzy drinks, condiments, junk

food, white bread and pasta can induce an

acid load that is not compensated for by fruit

and vegetables. This can cause chronic meta-

bolic acidosis and lead to metabolic compli-

cations. Increasing acidosis can reduce the

ability of insulin to bind at appropriate re-

ceptors in the body and reduce insulin sensi-

tivity, said the researchers. [Diabetologia2013;doi 10.1007/s00125-013-3100-0]

To test the hypothesis, they followed

66,485 women from the E3N* study for new

diabetes cases over 14 years. Their dietary

acid load was calculated from their potential

renal acid load (PRAL) and their net endog-

enous acid production (NEAP) scores, both

standard techniques for assessing dietary

acid consumption from nutrient intake.During follow-up, 1,372 new cases of type

2 diabetes occurred. In the overall population,

those in the top quartile for PRAL had a 56

percent increased risk of developing type 2

diabetes compared with the boom quartile.

Women of normal weight (body mass in-

dex [BMI] 25) had the highest increased risk

(96 percent for top quartile versus boom),

while overweight women (BMI 25) had

only a 28 percent increased risk (HR 1.28,

95% CI 1.00, 1.64). Statistically signicant

trends in risk across quartiles were observed

in both groups (p for trend


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Breastfeeding prevents obesity in mother

and child

Dr. Maria Katrina Florcruz

The initiation of breastfeeding is an es-

sential part of intrapartum and new-

born care. Thereaer, the maintenance

of exclusive breastfeeding is highly encour-

aged because of the benets it can give to both

the mother and child, including obesity pre-vention.

According to Dr. Maria Asuncion Silves-

tre, neonatologist at the University of the

Philippines-Philippine General Hospital,

Manila, Philippines, breast milk contains

nutrients and minerals that are optimal for

the babys sleep, growth and development.

While appropriate solid food is introduced

at 6 months, breastfeeding should be contin-ued until 2 years and beyond.

Silvestre explains that there is beer ap-

petite regulation when an infant is exclu-

sively breastfed. This is due to the endo-

cannabinoid receptor system that is present

in the babys developing brain and in hu-

man milk. Due to this, there is regulation

of energy balance and food intake at four

functional levels within the brain and pe-riphery, namely the limbic system, hypo-

thalamus and hindbrain, intestinal system

and adipose tissue. [Exp Biol Med (May-

wood).2005;230(4):225-34]

Exclusive breastfeeding also prevents

forced feeding the baby, which is encoun-

tered in bole and formula feeding. At the

same time, the baby is not subjected to the

unchanging sweet and creamy taste of for-

mula, said the speaker.

Silvestre cited studies which showed that

breastfeeding for at least 2 months strongly

protects a baby from developing obesity later

in life. In addition, there is stronger protectionfrom obesity in babies who were exclusively

breastfed. [Pediatrics. 2005; 115:1367-1377]

In another study, it was found that there

is an inverse association between the dura-

tion of breastfeeding and the babys risk of

being overweight later in life.[Am J Epide-

miol.2005;162(5):397-403] Silvestre also cited

a cohort study done among school children

in Japan which showed that breastfeeding isassociated with a decreased risk of becom-

ing overweight and obese. [JAMA Pediatr.

2013;167(10):919-25]

Breastfeeding also protects mothers against

obesity, says Silvestre, as it requires an aver-

age of 500 extra calories per day. Breastfeed-

ing brings about short-term changes in in-

sulin and glucose. She further adds that for

every year that a mother breastfeeds, there isa corresponding decrease in risk in develop-

ing diabetes later in life. Breastfeeding helps a

mother return faster to her ideal body weight

and signicantly reduces hip circumference

as early as 1 month post-partum.


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High-protein diet, meal replacements can

reduce rebound weight gain

Rajesh Kumar

Meal replacement and a high-proteindiet can help in maintaining weightloss by reducing rebound weight

gain, according to a meta-analysis of 20 ran-domized controlled trials (RCTs).

The body has several defense mechanismsagainst weight loss, such as increased hunger,lower energy metabolism and relapse to oldhabits, said researcher Dr. Erik Hemmings-son of the Karolinska Institutets Clinical Epi-demiology Unit and the Obesity Centre at Kar-olinska University Hospital in Solna, Sweden.

If the problem of rebound weight gaindidnt exist, obesity would be relatively easyto treat. There have been several possible

methods to facilitate long-term weight con-trol over the years, and now the database waslarge enough to make a systematic evaluationof existing studies.

Researchers combined the results of 20published RCTs involving 3,017 participantswho were either obese or overweight at thestart of the weight loss process. [Am J ClinNutr2014; doi: 10.3945/ajcn.113.070052]

The studies examined the eects of anti-obesity drugs (3 arms; n=658), meal replace-ments (4 arms; n=322), high-protein diets (6arms; n=865), other diets (3 arms; n=564), di-etary supplements (6 arms; n=261), and exer-cise (5 arms; n=347) on rebound weight gainaer an intensive weight loss on low-caloriediet of


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Non-medical factors complicate weight-

loss surgeries

Dr. Yves Saint James Aquino

Apart from the medical and surgicalfactors, patients are aected by psy-chological, logistic and nancial rea-

sons that cause arition in bariatric surgery,said Dr. Jose Antonio Salud, chairman of the

Department of Surgery in The Medical City,Pasig, Philippines. Arition refers to patientsundergoing surgical operations for weightloss who fail to follow-up regularly and even-tually drop out, patients who fail to lose suf-cient weight or patients who regain weightover time.

Successful bariatric surgery is dened ashaving percent excess weight loss greaterthan or equal to 50 percent, according toReinholds criteria, a measure developed in1982.

Unfortunately, this denition is not evi-dence-based and it is arbitrary, said Salud.He claried that estimating ideal weightvaries and the criteria do not take into con-sideration the type of operation performed,which may involve lap-adjustable gastric

banding, lap sleeve gastrectomy or lap

Roux-en-Y gastric bypass.In reality, the goal of bariatric surgery

is to reduce the health risks associated withbeing obese and to improve health-relatedquality of life, Salud added.

Failure of patients to return aer sur-gery has been associated with post-oper-ative physical complication, poor weightloss, poor nutrition and poor resolution ofobesity-related comorbidities. Non-com-pliance to post-operative therapy may also

be caused by psychological, logistic and -

nancial diculties [Obes Surg.2012;22:1640-1647].

In the Philippines, close to 10 percent ofpatients live out of town and far from theclinic. Some patients claim to be busy or areafraid of further interventions, while othersfeel they can manage the problem withouthelp from their doctors. And since the sur-

gical procedure is typically excluded fromhealth insurance, patients could not aordsucceeding consultations.

Some of the technical reasons for thearition may involve band-related prob-lems, esophageal dysmotility or inadequatesleeve resection. Patients may also fail tolose substantial weight due to excessiveeating, abnormally low metabolic rate andhyper-ecient intestinal absorption [Surg

Obes Rel Dis.2005;1(6):573-579].Psychological predictors to inadequate

weight loss include personality disorders,history of binge eating, emotional eatersand history of depression. However, anxi-ety disorders, self-esteem issues, history ofsexual or alcohol abuse were not correlat-ed with inadequate weight loss [Obes Surg.2012;22(1):70-89].

Surgical correction aer primary bar-iatric operation is technically more di-cult, with higher rate of complications andmortality and lower success rate than therst procedure. Important non-medical as-pects of weight loss therapy such as proac-tive support and peri-operative counselingand education may minimize inadequateweight loss post-surgery. A multi-disciplin-ary care involving internists, psychologistsand other specialists may help prevent ari-tion in bariatric surgery, explained Salud.


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Gestational weight gain may lead to obesity

Dr. James Salisi

Forty-ve percent of pregnant womenin the US are overweight or obese andalmost half begin their pregnancies as

either overweight or obese, according to astudy cited by Dr. Maria Jesusa Banal-Silao, afellow of the Philippine Society of Reproduc-tive Endocrinology and Infertility.

For women in the reproductive age, preg-nancy is a potential risk factor for the de-velopment of obesity. There is also a naturalincrease in body mass index (BMI) as thepregnancy progresses. Moreover, pregnan-cy can be a trigger for the development ofobesity due to excessive weight gain andlong term weight retention.

According to Banal-Silao, retainedweight after delivery may be harmful as the

adipose tissue tends to accumulate in thevisceral compartment. Evidence suggeststhat there are associations between exces-sive gestational weight gain and increased

birth weight and postpartum weight reten-tion.

The speaker further explained that ges-tational weight gain is a risk factor forshort-term post partum weight retention

and thus for becoming overweight in wom-en. An average of 1 to 2 kg of weight that isgained during pregnancy is retained at 6 to18 months postpartum. About 14 to 25 per-cent of women will have substantial weightretention of greater than 4.55 kg.

Gestational weight gain recommenda-tions by the Institute of Medicine (IOM) aimto optimize outcomes for the mother and in-fant. The maternal and infant outcomes for

obese and overweight women may not beadversely aected if they gain less than the

IOM recommendations.Banal-Silao added that gestational weight

gain (GWG) may also determine the long-term risk of being overweight in women. Ameta-analysis concluded that GWG in ac-

cordance with IOM recommendations is as-sociated with long-term eects on postpar-tum weight retention. [Am J Clin Nutr. 2011;94 (5): 1225-1231]

In order for postpartum women to dealwith excess GWG, Banal-Silao recom-mended regular monitoring of weight,promotion of appropriate pre-pregnancyweight gain and postpartum weight loss,

and encouragement of maintenance of anactive postpartum lifestyle and breast-feeding.

Banal-Silao said that breastfeeding thatis frequent and high-intensity is associ-ated with less postpartum weight reten-tion at all follow-up times. It may nothave an impact on short term weight loss

but women who breastfed their infants forat least 3 months had lower weight gain

at 8 years postpartum and lasted until15 years.

Gestational weight gain is a risk factor for short-term postpartum weightgain for women.


15/38


Lack of lactobacilli linked to vulvovaginal

atrophy

Angeline Woon

Menopausal women and those withvulvovaginal atrophy tend to haveless lactobacilli in their mid-vaginal

regions, say US researchers.The researchers, from Johns Hopkins

University and the University of Mary-land, characterized vaginal microbiota froma group of women between the ages of 35and 60. They found that the composition ofvaginal microbiota changes as women gothrough menopause.

Women with vulvovaginal atrophy, acommon cause of vaginal dryness and sex-ual pain, tended to have microbial composi-tions that were not dominated by lactobacilli.Compared to women with no vulvovaginalatrophy, the women with mild or moderatevulvovaginal atrophy had a 25-fold greaterodds of having a bacterial mix dominated

by microbes from the genus Streptococcusand Prevotella versus Lactobacillus crispatus(adjusted odds ratio, 25.89; 95% credible in-terval, 2.98-406.79).

Postmenopausal women tended to have

more microbes from the genus Streptococcusand Prevotella, as well. In comparison, wom-en whose vaginal microbiota were domi-nated by L. crispatusandL. inerstended to

be premenopausal. Perimenopausal womenwere more likely to be classied to have amix dominated by Streptococcus and Pre-votella, or L. gasseri, according to the studypublished in Menopause. [doi: 10.1097/

GME.0b013e3182a4690b]The study, led by lead author Dr. RebeccaBrotman (Ph.D.), assistant professor in the

department of epidemiology and publichealth at the University of Maryland Schoolof Medicine in Baltimore, Maryland, had87 participants. The women were classiedinto groups according to their menopausalstatus, premenopausal (n=30), perimeno-pausal (n=29) or postmenopausal (n=28) us-

ing the Stages of Reproductive Aging Work-shop guidelines. Out of the total, 19 womenhad signs of mild or moderate vulvovaginalatrophy.

The mid-vaginal region was sampled,and 16S ribosomal RNA gene analysis wasused to characterize the bacterial commu-nities, which were then clustered into sixmain community state types (CST). Four of

these CSTs were dominated byL. crispatus,L. gasseri, L. iners or L. jensenii.Two of theseCSTs had a low abundance of lactobacilli:one was dominated by the genus Streptococ-cusand Prevotella;and the other,Atopobium.Signicant associations could be made be-tween menopause stage and CST (P=0.004),and between vulvovaginal atrophy and CST(P=0.002).

The authors concluded that when levelsof lactobacilli are low, the vagina tends to bedry. In light of their results, probiotics may

Women with vulvovaginal atrophy, a common cause of vaginal dryness and

sexual pain, tended to have microbial compositions that were not dominatedby lactobacilli.


16/38


be a welcome alternative due to the draw-

backs in current therapy.

Women with vulvovaginal atrophy symp-

toms use lubricants during intercourse or

vaginal moisturizers as rst-line therapies.However, these may have detrimental ef-

fects on the vaginal lining, or may alter the

bacterial mix and increase susceptibility

to infections. In moderate-to-severe cases,

low-dose estrogen in the vagina is the cur-

rent therapeutic standard, but not all wom-

en can use vaginal estrogen, such as cancer

survivors, and some wish to avoid hormone

treatment.

The authors cautioned that using lactoba-cilli products that are not native to an in-

dividual womans vagina may be harmful.

Personalized probiotics, or other methods

to manage the bacterial mix, may be the so-

lution to treating vulvovaginal atrophy.


17/38


Seah Yee Mey

Scientists have recently identied and de-veloped a novel class of molecules thatappears to inhibit inuenza virus rep-

lication, a new study reports. [ACS ChemicalBiology2013; doi: 10.1021/cb400400j]

Researchers at Rutgers University, NewJersey, US, engineered part of the inuenzavirus replication enzyme and used it to screena library of 800 small molecule fragments forpotential sites of enzyme inhibition.

Fragment screening led them to the discov-ery of a previously unknown metal ion bind-ing location in the active site of the enzymethat could be exploited to inhibit viral replica-tion. Based on the screen, the researchers then

designed a new class of compounds to selec-tively block the inuenza virus enzymatic ac-tivity. When tested on cell cultures, the com-pounds demonstrated antiviral activity.

Were at a key proof of principle stageright now, said Eddy Arnold, professor ofchemistry and chemical biology at Rutgers,whose laboratory carried out the research incollaboration with Edmond LaVoie, professor

and chair of medicinal chemistry also at Rut-gers, and virologist Luis Martinez-Sobrido ofthe University of Rochester, New York. Itsnot trivial to go from this point to actuallydelivering a drug, but were optimistic thisclass of inhibitors has all the right characteris-tics, he said.

Just as bacteria develop antibiotic resis-tance, Arnold noted that some strains of inu-enza have also started to develop resistanceto oseltamivir phosphate, which is currentlythe only orally available anti-inuenza drug.

Therefore, Arnold and his collaborators aresearching for other drugs, especially ones thattarget other parts of the virus. They selected

this particular viral enzyme because inhibit-ing its activity interferes with the virus abilityto steal material from human cells and dis-guise itself.

The approach used by Arnold and his col-laborators has also helped in the developmentof anti-HIV drugs. Merck targeted metal ion-containing active sites in an HIV enzyme todevelop a successful anti-HIV drug. Its truly

remarkable what they did, and were trying topursue similar logic with inuenza, Arnoldsaid.

Antiviral drug discovery is an essentialalternative to vaccines, especially duringpandemics when timely vaccine productionis dicult. While this approach is not new,the technology to produce the high-resolu-tion images of the H1N1 inuenza enzymestructure used by the Rutgers researchersto screen for inhibitors is only recently avail-able.

Novel engineered molecule inhibits

influenza virus replication

Researchers in the US have designed a new class of compounds to selectivelyinhibit the inuenza virus enzymatic activity.


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18 December 2013 Research Reviews

Oral anticoagulants and antiplatelet drugs reduce risk of secondary

VTE

Venous thromboembolism (VTE) is the third

most common cardiovascular disorder. Al-

though potentially fatal, it can be treated and pre-

vented with anticoagulants, but there is a trade-o

with the risk of major bleeding events.

A recent systematic review and network meta-

analysis compared the ecacy and safety of the oral

anticoagulants dabigatran (150 mg twice daily), ri-

varoxaban (20 mg/day), apixaban (2.5 mg and 5 mg

twice daily), vitamin K antagonists (standard dose,

target international normalized ratio [INR] 2.03.0;low dose, target INR 1.53.0), ximelagatran (24 mg

twice daily), and an antiplatelet agent (acetylsalicylic acid 100 mg/day) for the secondary prevention of VTE. Lit-

erature searches of the Medline, Embase and Cochrane Register of Controlled Trials databases were performed

to identify randomized controlled trials in which patients received anticoagulants, antiplatelet drugs, or placebo

or observation. Twelve articles were identied and 11,999 patients were evaluated for ecacy and 12,167 for

safety.

All treatments reduced the risk of recurrent VTE. Compared with placebo or observation, standard-dose vita-

min K antagonists showed the greatest eect (odds ratio [OR] 0.07; 95% CI 0.03-0.15) followed by dabigatran (OR

0.09; 95% CI 0.04-0.21); acetylsalicylic acid had the smallest eect (OR 0.65; 95% CI 0.39-1.03). Among these three

agents, the risk of major bleeding was highest for the standard-dose vitamin K antagonists (OR 5.24; 95% CI 1.78-

18.25) versus placebo or observation. The corresponding odds ratios for dabigatran and acetylsalicylic acid were

2.79 (95% CI 0.79-11.69) and 1.29 (95% CI (0.4-4.08). Fatal VTE recurrence and major bleeding events were rare.

Castellucci LA et al. Ecacy and safety outcomes of oral anticoagulants and antiplatelet drugs in the secondary prevention of venous thromboembolism:

systematic review and network meta-analysis. BMJ 2013; 347: f5133


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Suicide ideation in relatives bereaved by suicide

Relatives bereaved by suicide are known to be at increased risk of suicide themselves irrespective of whetherthey are genetically related to the deceased family member or friend. A recent study has indicated that thismay be due to suicide ideation linked to symptoms of depression and complicated grief, which is a proposed

clinical entity related to bereavement that is distinct from depression, anxiety and post-traumatic stress disorder.

The study is unique in that it oers a long-term assessment of the course of bereavement.

The researchers analyzed data collected from a community-based sample of 153 rst degree relatives and

spouses of 74 individuals who commied suicide between September 1999 and January 2002 in the Netherlands.

The participants completed self-report questionnaires assessing symptoms of complicated grief, depression, and

suicidal ideation 2.5 months (baseline), 13 months, and 96-120 months (810 years) aer the index suicide.Suicide ideation, depression and complicated grief were strongly mutually associated. A total of 26 percent suf-

fered from suicide ideation at baseline, compared with 9 percent at 96-120 months. Long-term suicide ideation

was linked to a history of aempted suicide and was strongly associated with an increased risk of complicated

grief and depression. However, these risks decreased over time. Long-term depression was more common among

women and those with low levels of mastery. Parents who lost a child were at greater risk of complicated grief.

Family-based therapy, support from a general practitioner, and/or mental healthcare did not aect the long-term

course of bereavement. Mutual support provided by voluntary clergy- or peer-led groups was associated with

an increased risk of complicated grief, but the researchers caution that this may be due to selection bias.

de Groot M & Kollen BJ. Course of bereavement over 8-10 years in rst degree relatives and spouses of people who commied suicide: longitudinal community based

cohort study. BMJ 2013; 347:f5519.Neal B. Trials in kidney disease time to EVOLVE. Ibid:2541-2542 (editorial).

Treatments fail to reduce cough in acute bronchitis patients

Acute bronchitis is one of the most common complaints encountered by primary care physicians. The condition is

primarily caused by viral infection and is generally self-limiting, but most patients continue to be prescribed anti-biotic treatments, particularly if they report discoloration of sputum. Given the global increase in antibiotic resistance,

this over-prescription is of concern. Since cough is the primary symptom of acute bronchitis, oral anti-inammatory

therapy has been suggested as a more appropriate treatment. However, a recent study in Spain has shown that neither

oral anti-inammatory nor antibiotic treatment is more eective than placebo at reducing cough frequency.

The prospective, parallel group, single-blind study included 416 adults aged 18-70 who presented with symptoms

of respiratory infection of less than 1 week duration, predominately cough but also sputum discoloration and at least

one of the following: dyspnea, wheezing, chest discomfort or chest pain. The patients were randomized to ibuprofen

600 mg three times daily (n=136), amoxicillin-clavulanic acid 500 mg/125 mg three times daily (n=137) or placebo three

times daily (n=143) for 10 days. Symptom duration was assessed with a diary.

The median number of days with frequent cough was 9 (95% CI 810) among the ibuprofen recipients compared

with 11 (95% CI 10-12) among those who received the antibiotic. However, this dierence was not statistically signi-

cant. Moreover, the probability of cough resolution was not greater than that of placebo for both ibuprofen (hazard

ratio [HR] 1.03, 95% CI 0.781.35) and amoxicillin-clavulanic acid (HR 1.23, 95% CI 0.931.61).

Llor C et al. Ecacy of anti-inammatory or antibiotic treatment in patients with non-complicated acute bronchitis and discoloured sputum: randomised placebo

controlled trial. BMJ 2013;347:f5762.


20/38


Coffee consumption positively correlated with all-cause mortality

Given the popularity of coee consumption world-

wide it is of no surprise that a recent study linkingcoee consumption with all-cause mortality has been

the subject of much comment, particularly since no such

association was observed with cardiovascular mortality.

In their study, the researchers evaluated observational

data from 43,727 individuals aged 20-87 years who were

enrolled in the prospective Aerobics Center Longitudi-

nal Study. All completed a medical history questionnaire

assessing their lifestyle habits and personal and family

history and underwent a baseline medical examination

between February 3, 1971 and December 30, 2002. Indi-

viduals with cardiovascular disease or cancer and those

who were underweight or had abnormal electrocardio-

graphic ndings were excluded, which le 43,727 in-

dividuals (33,900 men and 9,827 women with 699,632

person-years of follow-up) who met the inclusion crite-

ria and were observed for mortality from the baseline

examination to their date of death or December 31, 2003.

A total of 2,512 deaths occurred during the median 17-

year follow-up period. Multivariate analyses revealed anassociation between the consumption of >28 cups coee/

week and all-cause mortality in men only (hazard ratio

[HR] 1.21; 95% CI 1.04-1.40). However, stratication by

age indicated that coee intake >28 cups/week was asso-

ciated with all-cause mortality in both men and women

younger than 55 years (men: HR 1.56, 95% CI 1.301.87;

women: HR 2.13; 95% CI 1.26-3.59). Adjustments were made for age, baseline examination year, decaeinated

coee use, regular tea use, decaeinated or herbal tea use, physical inactivity, body mass index, smoking, alcohol

consumption, diabetes, hypertension, hypercholesterolemia, family history of cardiovascular disease, and physi-

cal tness.

The researchers stressed that further studies are needed to conrm their ndings, but they caution that young-

er individuals may be beer o avoiding excessive coee consumption (average >4 cups/day).

Liu J et al. Association of coee consumption with all-cause and cardiovascular disease mortality. Mayo Clin Proc. 2013; 88 (10): 1066-1074.


21/38


Mixed microbial preparation offers no protection against AAD

Antibiotic-associated diarrhea (AAD) is a common

complication among inpatients aged 65 yearstreated with broad-spectrum antibiotics, which is con-

cerning since Clostridium dicileinduced AAD (CDD)

can be life-threatening. A variety of microbial prepara-

tions have been tested with the aim of ameliorating or

preventing AAD and CDD by restoring the gut micro-

bial ora, but their ecacy remains controversial. Re-

cently, a multicenter ecacy trial found no evidence of

any protective eect of a multistrain lactobacilli and bi-

dobacteria preparation against AAD or CDD.

The double-blind study evaluated 2,981 inpatients aged 65 years who were randomized to receive the micro-

bial preparation containing 61010 live bacteria (n=1,493) or placebo (n=1,488) once daily for 21 days. All patients

had been exposed to one or more antibiotics in the preceding 7 days or were about to begin antibiotic treatment.

Follow-up was for 8 weeks.

A modied intention-to-treat analysis of 2,941 participants revealed that AAD (including CDD) occurred in

10.61 percent of patients, and the incidence was similar between the treatment and placebo groups (relative risk

[RR] 1.04, 95% CI 0.84-1.28). Moreover, CDD was only observed in 0.99 percent, and again the incidence was

similar in both groups (RR 0.71, 95% CI 0.34-1.47). The microbial preparation did not appear to have any protec-

tive eect against diarrhea severity, frequency of abdominal symptoms, length of hospital stay or quality of life.

The researchers commented that a beer understanding of the pathophysiology of AAD is required.

Allen SJ et al. Lactobacilli and bidobacteria in the prevention of antibiotic-associated diarrhoea and Clostridium dicile diarrhoea in older inpatients

(PLACIDE): a randomised, double-blind, placebo-controlled, multicentre trial. Lancet 2013; Aug 7 pii: S0140-6736(13)61218-0. doi: 10.1016/S0140-

6736(13)61218-0 [Epub ahead of print]


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22 December 2013 Conference Coverage

Adult brain continues to regenerate

neurons

7th Asian Society Against Dementia International Congress, October 9-12, Cebu, Philippines

Elvira Manzano

N

eurogenesis, the birth of neurons

or nerve cells in the hippocampus,

continues during adulthood, new

research suggests.A retrospective study of hippocampal cells

from deceased patients has shown that a sig-

nicant proportion (35 percent) of these neu-

ral cells are subject to exchange, resulting in

the addition of 700 new cells to the brain per

day per individual. This corresponds to an

average turnover rate of 1.75 percent of the

renewing cells per year during adulthood,

with no dierence in rates between genders(p=0.41). [Cell 2013;153:1219-1227]

Human studies like this are sparse but

encouraging, said Dr. Robert Hoerr, head of

geriatrics/CNS, Department of Clinical Re-

search, Dr. Willmar Schwabe GmbH & Co.

KG, in Karlsruhe, Germany, who was not in-

volved in the study. He said this adds weight

to the issue of adult neurogenesis in humans

and gives indirect indication of the extent ofneurogenesis which may have an impact on

brain function. Hoerr cited data from this

study, and other studies, during his plenary

lecture on hippocampal neurogenesis.

It has long been debated whether adult

neurogenesis decreases or increases through-

out life. A seminal study in 1998 provided the

only direct evidence so far of adult neurogen-

esis in humans, although it did not show the

extent of neurogenesis, or if there is any func-

tional signicance to it. [Nat Med1998;4:1313-1317]

In the current study, researchers measured

the amount of radioactive carbon 14 isotope

(14C) in genomic DNA from the hippocampal

cells of deceased patients (19-92 years of age),

to determine cell age. A mathematical model

was then developed to determine the rate of

cell turnover in both neural and non-neural

cells of the patients.A higher rate of cell turnover existed in

the non-neural cells than in the neural cells

(51 percent vs 35 percent), with an annual

turnover rate of 3.5 percent. This however

declined with age. By comparison, the neural

cells appeared to be less aected by aging.

Studies in mice and in humans linking neu-

rogenesis to Alzheimers disease (AD) yield-

ed conicting results [J Neurosci2007;27:6771-

6780; PNAS 2004;101:343-347]. In one study in

A new study suggests that the typical adult brain is regenerating an averageof 700 new cells per day.


23/38


humans, neurogenic abnormalities with AD

diered between phases and areas of neuro-

genesis, as well as stages of AD. [Neurobiol Dis

2012;47:155-162]

With progressing AD, choline-acetyl-transferase activity and hippocampal stem

cells decrease, proliferation of progenitor

cells increase, but migratory and post-miotic

cells largely remain unchanged, Hoerr said.

Several factors may inuence hippocampal

neurogenesis, he added. These include signal-

ing molecules, transcription factors, growth

factors, neurotransmiers and hormones.

Animal studies have shown that all current-

ly available anti-dementia drugs (donepezil,

galantamine, memantine), as well as antide-

pressants (eg, uoxetine), physical and men-

tal activities promote neurogenesis.

Ginkgo biloba extract (EGb 761) has also

been shown to stimulate neurogenesis in

mice. It reduced amyloid beta oligomers and

restored cAMP response element-bindingprotein (CREB) phosphorylation in the hippo-

campus, suggesting that EGb 761 not only has

benet in the treatment of patients with AD,

but may also have an eect in prevention or

disease modication. [FASEB J2007;21:2400-

2408]

Overall, the studies provide new informa-

tion on hippocampal neurogenesis and en-

courage additional research. Further studies

to determine if reduced neurogenesis is asso-

ciated with depression in humans would be of

interest, Hoerr concluded.

Playing video games boosts cognitiveperformance in seniors

Elvira Manzano

Video game training can improve cog-

nitive performance in healthy older

adults, new research has found.The study involving participants aged 60-

85 years showed that 12 hours of video game

training spread over 1 month increased their

multi-tasking capabilities, as well as cogni-

tive control (working memory and sustained

aention), beer than younger adults who

played it for the rst time. The improvements

were sustained 6 months aer the training had

ended. There were also increases in midline

frontal theta, or low frequency oscillations in

the prefrontal cortex, which is associated with

aention. [Nature2013; 501:97-101]

In a trial involving older adults, aged 60-85, 12 hours of video gamingspread over a month was associated with improvements in their multi-tasking abilities and cognitive control.


24/38


The study researchers warned the ndings

should not be taken to suggest that any activ-

ity or video game would improve cognition

in seniors. However, it does oer evidence

of generalized positive eects of video gametraining on cognitive control of older adults,

with enhancements comparable to those of

younger adults who are habitual video game

players, said Associate Professor Christopher

Chen from the Department of Pharmacology,

National University of Singapore.

Chen, who was not involved in the study,

said video game participation may be a po-

tential intervention strategy to increase cogni-

tive reserve in seniors.

The study by researchers at the University

of California in San Francisco, US, provides

optimism for use of an adaptive interference-

rich, video game approach as a therapeutic

tool for the diverse populations that suer

from cognitive control decits. It also stress-

es the importance of a targeted training ap-

proach.

The researchers used a custom-designed

three dimensional (3-D) race car video game

(NeuroRacer) and made the seniors drive at

full speed in between road signs for up to 12

hours on a laptop. The game gets harder as

they succeed and easier when they get frus-

trated. Driving up winding mountain roads

while picking out occasional road signs madethem work at both skills. This keeps them

challenged and engaged while having fun,

Chen said. Learning also improves when the

brains reward system is turned on, such as

when someone is having fun.

However, the most meaningful endpointsfor intervention in seniors, according to this

clinician-scientist, would be slowed rate of

age-related cognitive decline or reduced risk

of developing Alzheimers disease.

Controlled studies that use such endpoints

are however undoubtedly expensive and have

to be conducted over long periods of time.

Most likely, studies should also use multiple

intervention strategies, including exercise,

cognitive and social stimulation, Chen said.

In addition to that, a validated measure of

cognitive reserve (brain capacity built up dur-

ing early life), should be used when assessing

cognition in seniors. This does not preclude

the use of more challenging tests that are pa-

thology-specic and biomarkers in patients

with high cognitive reserve. Higher rate of

decline aer diagnosis may also be relevant

for clinical trials, he added.

Finally, clinicians need to have a beer

understanding of the neuroimaging cor-

relates, underlying genetic factors and the

role of cerebrovascular factors on cognitive

reserve. We need to develop and show ef-

cacy of interventions to improve cogni-

tive reserve and brain resilience, Chenconcluded.


25/38

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26/38

26 December 2013 In Practice

Management of codeine addiction in

primary care

Dr. Melvin Wu

Resident Physician

National Addictions Management Service (NAMS)

Institute of Mental Health, Singapore

GPs can be crucial to identifying and

helping codeine addicts get profes-sional help to kick their habit.

Codeine belongs to the opioid class of

substances that, in the short-term, can cause

drowsiness and endanger the patients life

while operating machinery or driving. At

higher dosages or when used in combination

with other substances such as benzodiaze-

pines and alcohol, codeine can cause respira-

tory depression and even death.Long-term use of codeine can lead to de-

pendence, characterized by tolerance and

withdrawal symptoms such as cravings,

runny nose, yawning, insomnia, weakness,

irritability, muscle spasms, body aches, diar-

rhea and vomiting. The paern of codeine use

becomes compulsive when the person has a

loss of control over its use. In other words, he

or she has become addicted to codeine. Therewill invariably be problems at home, work

and/or school in relation to this paern of use.

Reviewing the history of the persons clinic

visits is one way to identify if he or she may

have a problem with codeine addiction. For

example, they may have regular visits and

oen request for the same type of cough

mixture. They may be resistant to the idea

of changing the type of cough mixture. This

person may also ask for an extra bole of the

medication.

A simple way

to assess the pos-

sibility of addic-

tion would be to

ask the person if

he or she has had

problems with

addiction in thepast. A history of

addiction to any

substance will

increase the risk

that the person

may also be addicted to codeine.

GPs play an important role in helping the

person as they are oen the rst point of con-

tact. A non-confrontational way of approach-ing the subject would be to oer help for the

presenting problem, usually a chronic cough.

Start by saying, I notice that you have

been having this cough for quite a while now

and I am rather concerned. Next, oer inves-

tigations, eg, chest X-rays, and referral to a re-

spiratory physician.

If the person accepts this, it might point to

a genuine underlying disease concern. If thereare signs that this person is abusing codeine,

oer to change the type of cough mixture.

Choose a non-opioid based cough mixture

like diphenhydramine or ivy leaf extract. Be

rm in your stand that you will not continue

to prescribe codeine.

Providing psychoeducation to this person

on the dangers of long-term codeine use may

sometimes help them to open up and ask for

help.


27/38


28/38


gressive treatment. Inammatory processes

of the scalp include lichen planopilaris and

discoid lupus erythematosus.

Diagnosis

A thorough clinical history and careful

examination will help to establish a diag-

nosis. Doctors can use trichoscopy, a hand-

held dermatoscope to assess the hair and the

scalp. In FPHL, trichoscopy will show hair

diameter heterogeneity. Other relevant tools

for hair loss diagnosis include blood tests

with iron level measurements, thyroid func-

tion tests, autoimmune markers and hor-

monal assessment. In some dicult cases,

a skin biopsy of the scalp may be needed.

Conditions like scarring alopecia oen man-

date scalp biopsies.

Treatment

Optimal results for hair loss management

stem from early treatment as it is always easi-er to arrest hair loss at an earlier stage than to

grow hair at a later stage. GPs can help recog-

nize the beginning stages of hair loss, counsel

patients on their options and refer to derma-

tologists for treatment.

Treatment for hair loss requires a tailored

approach. Any underlying causes should be

corrected, including iron deciency, thyroid

abnormalities and other metabolic abnormal-ities. This should be followed with regular

follow-ups with photographic documenta-

tion to assess for treatment results. Realistic

expectations need to be set with the patient.

Treatments tend to work beer when initiated

early or used in combinations.The goal of treating FPHL is to stop hair

loss and stimulate hair growth. The treat-

ment for FPHL can be divided into andro-

gen-independent and androgen-dependent.

Androgen-independent therapies include

topical minoxidil. Minoxidil is currently the

standard of care for FPHL and its ecacy has

been proven in randomized, double-blinded

trials. Its mechanism of action remains specu-

lative and is thought to involve vasodilatory

and anti-androgenic eects. It is usually well

tolerated. Some adverse eects to counsel

patients about include: facial hair if solution

drips beyond hair line, itch and dandru.

Androgen-dependent therapies for FPHL

usually consist of androgen receptor antago-

nists like spironolactone and cyproterone ac-

etate. Spironolactone is a diuretic that reduces

the total testosterone and blocks the androgen

receptor. It has been used to treat FPHL o-

label. Spironolactone must be used carefully

in females of child bearing age as it is contra-

indicated in pregnancy. Patients started on

spironolactone must be counseled that they

will need regular monitoring of their potas-

sium levels, whilst some may expect transientmenorrhagia. Cyproterone acetate has shown

ecacy in treating FPHL in women of normal

or raised androgen levels.

The treatment of alopecia areata depends

on the area of involvement. For small areas of

involvement, intralesional corticosteroids can

be used. Rapidly progressive diuse alopecia

areata can be dicult to dierentiate from

other causes of diuse hair loss and such pa-tients are best referred for specialist opinion.

GPs can help recognize the

beginning stages of hair loss,

counsel patients on their options

and refer to dermatologists

for treatment


29/38


A scalp biopsy may sometimes be needed to

ascertain the diagnosis. Rarely, systemic corti-

costeroids may be needed for short periods to

arrest rapidly progressing hair fall. For alope-

cia areata involving large areas of scalp, topi-cal immunotherapy is also a treatment option.

Realistic results for hair regrowth oen

take many months to achieve. Providing

the necessary psychological support for pa-

tients is very important. While waiting for

hair to regrow, patients can seek to camou-

age hair loss using various methods, in-

cluding hair pieces, wigs or scalp camou-

aging agents.

Hair transplant can be considered in patients

who have failed medical treatment or whose

advanced condition is unlikely to benet from

medical treatment. Such patients should have

stable hair loss, a good hair donor area, good

health and reasonable expectations.

A specialist opinion should be sought

when the diagnosis is uncertain or when there

is a doubt regarding treatment options. In

treatment of hair loss, a good patient-doctor

relationship is paramount. A referral may be

made when a doctor is experiencing time con-straints or limited resources, and a patients

desires a more in-depth discussion regarding

their hair loss and options.

Conclusion

Hair loss in women is a signicant prob-

lem. It is important to educate and coun-

sel patients about the treatment options for

hair loss. This should be done with com-

passion and patience to achieve the best

treatment outcome for the patient. While

numerous unproven and non-medical com-

mercial options for hair loss beckon, would-be

patients must realize that only doctors are

able to provide quality, scientically-based

treatments for their hair loss.

Online Resources:

American Hair Loss Associationhp://www.americanhairloss.org/

American Academy of Dermatologyhp://www.aad.org/media-resources/stats-and-facts/conditions/hair-loss

National Alopecia Areata Foundationhp://www.naaf.org


30/38

30 December 2013 Calendar

DECEMBER

International Diabetes Federation (IDF) World

Diabetes Congress

2/12/2013 to 6/12/2013

Location: Melbourne, AustraliaInfo: IDFTel: (32) 2 543 1631Fax: (32) 2 403 0830E-Mail: [email protected]: www.idf.org/worlddiabetescongress

American Society of Hematology (ASH) Annual

Meeting

7/12/2013 to 10/12/2013Location: New Orleans, Louisiana, USInfo: ASHTel: (1) 202 776 0544Fax: (1) 202 776 0545Website: www.hematology.org

San Antonio Breast Cancer Symposium (SABCS)

2013

10/12/2013 to 14/12/2013Location: San Antonio, Texas, USInfo: Rich Markow, Director, SymposiaTel: (1) 210 450 1550Fax: (1) 210 450 1560E-Mail: [email protected]: www.sabcs.org

Health Systems in Asia: Equity, Governance and

Social Impact

13/12/2013 to 16/12/2013Location: SingaporeInfo: L. Copeland, ElsevierEmail: [email protected]: www.healthsystemsasia.com

International Conference on Obstetrics and

Gynaecology (ICOG) 2013

24/12/2013 to 25/12/2013Location: Bangkok, Thailand

Info: WASETTel: (1) 971 559 099 620Website: www.waset.org/conference/2013/12/bangkok/icog

JANUARY

17th Bangkok International Symposium on HIV

Medicine 2014

15/1/2014 to 17/1/2014

Location: Bangkok, ThailandInfo: Mrs. Kesdao Nanthapisal, HIV Netherlands AustraliaThailand Research Collaboration (HIV-NAT)Tel: (662) 652 3040, Ext. 123Fax: (662) 252 7574Email: [email protected]: www.hivnat.org/bangkoksymposium

16th Congress of the European Society for

Sexual Medicine

29/1/2014 to 1/2/2014Location: Istanbul, TurkeyInfo: ESSM Secretariat

Tel: (39) 25 6601 625Fax: (39) 27 0048 577Email: [email protected]: www.essm-congress.org/congress

2nd International Conference on Nutrition and

Growth30/1/2014 to 1/2/2014Location: Barcelona, SpainInfo: Kenes InternationalTel: (41) 22 908 0488Fax: (41) 22 906 9140Email: [email protected]: ng.kenes.com

UPCOMING

10th Asian Pacific Congress of Hypertension

(APCH)

12/2/2014 to 15/2/2014Location: Cebu, PhilippinesInfo: APCH SecretariatTel: (66) 2 748 7881

Fax: (66) 2 748 7880E-Mail: [email protected]: www.apch2014.org


31/38

31 December 2013 Calendar

3rd Global Congress for Consensus in Pediatrics

& Child Health (CIP)

13/2/2014 to 16/2/2014Location: Bangkok, ThailandInfo: Paragon GroupTel: (41) 22 533 0948

Fax: (41) 22 580 2953E-Mail: [email protected]: www.cipediatrics.org

19th World Congress on Controversies in

Obstetrics, Gynecology & Infertility (COGI)

20/2/2014 to 23/2/2014Location: Macau, ChinaInfo: COGI SecretariatTel: (972) 73 706 6950Fax: (972) 3 725 6266E-Mail: [email protected]: www.congressmed.com/cogimacau

5th Congress of Asia Pacific Pediatric Cardiac

Society (APPCS)

6/3/2014 to 9/3/2014Location: New Delhi, IndiaInfo: APPCS SecretariatTel: (91) 11 2658 8116Fax: (91) 11 2658 8663E-Mail: [email protected]: www.appcs2014.org

Asian Pacific Association for the Study of theLiver (APASL) 2014

12/3/2014 to 15/3/2014Location: Brisbane, AustraliaInfo: Gastroenterological Society of AustraliaTel: (61) 3 9001 0279Fax: (61) 3 9802 8533E-Mail: [email protected]: www.apasl2014.com

WCO-IOF-ESCEO World Congress of Osteoporosis

2/4/2014 to 5/4/2014Location: Seville, Spain

Info: Yolande Piette CommunicationTel: (32) 4 254 12 25Fax: (32) 4 125 12 90Email: [email protected]: www.wco-iof-esceo.org

20th ASEAN Federation of Cardiology Congress

2014

12/6/2014 to 15/6/2014Location: Kuala Lumpur, MalaysiaInfo: AFCC SecretariatTel: (60) 3 7955 6608

Fax: (60) 3 7956 6608Website: www.nham-conference.com/?event=3&cmd=home


32/38

32 December 2013 After Hours

Searching out Italian food and

wine heavenI N P I E D M O N T

Situated in Italys North-west, the Piedmont is rich in culture and history. Surrounded on

three sides by the Alps it also features the highest mountain peaks and largest glaciers in the

country. The Piedmont is also well known for its culinary delights and Alexandra Kirsten

reports on her recent trip for a lile wine tasting and true hunting.

It was the Alps that gave the Piedmont

(in Italian, Piemonte) its name: foot of

the mountain. While the mountains

attract skiers and other sportspeople, the

most interesting parts for food lovers are

the wavering hills and valleys of Langhe

and Monferrato. Dotted with small townsand pittoresque castles, the hills are home

to uncountable vineyards. No wonder the

special grapes in this region produce some

of the best wines from Italy such as Barolo,

Barbaresco, Barbera, Dolcetto and Moscato

DAsti.

Food and wine

Whilst in Piedmont, it is well worth go-ing on a tour of the vineyards. Many of

them especially the smaller ones offer

free wine tasting and a look into the wine

cellar. If you find a chatty wine dresser, you

will also get a small introduction to wine

growing, a history of the Piedmont, Italian

politics or, depending on your Italian, any-

thing else.

If you feel peckish after a long day of

tasting, the Piedmont offers unique food.

Its cuisine is mostly known for the immense

variety of antipasti (starters): in any other


33/38


area, these filling dishes and the ubiquitous

grissini, long thin breadsticks, would

easily qualify as main courses. Famous ap-

petizers are bagna cuda, a butter saucemade with garlic and anchovies and served

with raw vegetables, insalata di carne cru-

da, minced raw beef with a marinade of ol-

ive oil and garlic or frittata, a baked veg-

etable omelet. In the unlikely case that you

are still hungry after these starters indulge

yourself with meat cooked in Piedmontese

red wine or, more on the vegetarian side,

with risotto and tajarin, a special kind ofpasta. If you are [very] adventurous try the

Finanziera, a dish made of cockscombs

and mixed organs or fried pigs feet called

Batsoa, literally translated as silk stock-

ings. Not everybodys delight though.

Gold of the earth

The Piedmontese cuisine would be less

famous without its favorite ingredient: thetruffle. Every year in autumn the small

town of Alba becomes the host of the Inter-

national Truffle Fair. Two weeks are dedi-

cated to the tuber magnum pico, includ-

ing gastronomic events and cultural and

folkloristic presentations.

Once known as witches food, truffles are

now beloved by gourmet chefs the world

over. The rare fungus grows only from Sep-tember to January, needs special soil, and

cannot be cultivated. This, and their ex-

traordinary taste, explain why truffles are

so expensive. In addition, truffles grow

underground. They can only be found by

very delicate noses, so the trifulau (truf-

fle gatherer) needs help from a canine com-

panion.

During the truffle season going on a

truffle hunt with a Trifulau and his dog is

an interesting experience. You will learn all

about black and white truffles and see the

dog in action. But be warned, you are not

allowed to keep the truffles you find.

The capital of baroque

Its not all about food and wine in the

Piedmont. Turin, the regions beautiful

capital is known as the little Paris. Wideboulevards, palaces, churches and castles

built during the kingdom of the Savoia give

the city an aristocratic look. Turin is an im-

portant hub of technology and culture: it

is not only home to the FIAT automobile

company but also to the famous Shroud

of Turin. But being the capital of the food-

loving Piedmont theres no wonder that the

Torinesi are also master chocolatiers. Gi-

anduja, chocolate made from hazelnuts


34/38


growing in the area, is known and beloved

world-wide.

If you finally need a break from all the

food and culture, go and see the Pink Bun-

ny of Coletto Fava. On a hill in the northernpart of the country, a 60 meter long toy bun-

ny made of straw-stuffed fabric has been

laid out by a Viennese art group. Hikers and

tourists are encouraged to climb the over-

sized stuffed animal and even to lie down

for a nap or picnic on the wooly carcass.

You can be sure to find no truffles or grapes

there.

Photos courtesy of Alexandra Kirsten.


35/38

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36/38

36 December 2013 Humor

Lets go back to your childhood!

You seem to be in good health.An early sign that eventually

youre going to be sick!

I can never tell if its a veinor an artery!

Youre back on solidsMr. Slickmore!

Youre right Doctor. Theres no

shortage of beds in this hospital,just too many patients!

I eat so much non-fattening food,how come Im still fat?

Its mid-life alright, but you havent reached the crisis yet!


37/38

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For A 5-minute UpdateGo towww.mims.asia/video_series


38/38

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