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June 2012

More intensive dialysis improves patient outlook

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Low back pain: Current concepts

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Lutein crucial for early cognitive development

SINGAPORE FOCUS

Feeding difficulties can persist into adulthood

For the Prevention oF Stroke and SyStemic emboliSm in PatientS with non-valvular atrial Fibrillation

STROKE pREvEnTiOn

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C: Dabigatran etexilate I: Primary prevention of venous thromboembolic events in adult patients who have undergone elective total hip or knee replacement surgery. Prevention of stroke & systemic embolism in patients w/ non-valvular atrial fibrillation. D: Prevention of VTE Following elective knee replacement surgery: Initially 110 mg w/in 1-4 hr of completed surgery, then 220 mg once daily thereafter, for 10 days. Following elective hip replacement surgery: Initially 110 mg w/in 1-4 hr of completed surgery, then 220 mg once daily thereafter, for 28-35 days. For both surgeries, if haemostasis is not secured, initiation of treatment should be delayed. If the treatment is not started on the day of surgery, then treatment should be initiated w/ 2 cap once daily. Elderly & renal impairment (CrCl 30-50 mL/min) Initially 75 mg w/in 1-4 hr of completed surgery, then 150 mg once daily thereafter. Treatment should be continued for a total of 10 days after knee replacement surgery & 28-35 days after hip replacement surgery. Prevention of stroke & systemic embolism in patients w/ non-valvular atrial fibrillation 150 mg bd. Elderly ≥80 yr, patient at risk of bleeding 110 mg bd. A: Swallow whole, do not chew/crush. CI: Severe renal impairment (CrCl <30 mL/min), active clinically significant bleeding, organic lesions at risk of bleeding, spontaneous or pharmacological impairment of haemostasis, hepatic impairment or liver disease expected to have any impact on survival. Concomitant treatment w/ systemic ketoconazole. SP: Haemorrhagic risk ie congenital or acquired coagulation disorders, thrombocytopenia or functional platelet defects, active ulcerative GI disease, recent biopsy or major trauma, recent intracranial haemorrhage or brain, spinal or ophth surgery, bacterial endocarditis; acute renal failure, moderate renal impairment. Concomitant use w/ drugs that may increase risk of bleeding. Surgery or invasive procedures; spinal & epidural anaesth; lumbar puncture; post-procedural period, hip fracture surgery. Patients at high surgical mortality risk & w/ intrinsic risk factors for thromboembolic events. Patients <18 yr. Pregnancy & lactation. AR: Bleeding, anaemia, haemorrhage, haematoma, haematuria, procedural complications, ALT ≥3x ULN, decreased Hb, GI disorders. DI: Unfractionated heparins & heparin derivatives, LMWH, fondaparinux, desirudin, thrombolytic agents, GPIIb/IIIa receptor antagonists, clopidogrel, ticlopidine, dextran, sulfinpyrazone, vit K antagonists, amiodarone, verapamil, quinidine, clarithromycin, ketoconazole, NSAIDs w/ elimination half-life >12 hr; P-glycoprotein inducers eg rifampicin, St. John’s wort or carbamazepine.

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warfarin prevents 64% of strokes. Pradaxa 150 mg bid prevents an additional 35% of the remaining strokes or systemic embolisms1,2,5

pRADAXA 150 mg bid provides significantly superior stroke prevention vs well-controlled warfarin1,2

35% reduced risk of stroke or systemic embolism vs well-controlled warfarin (international normalized ratio [inR] 2.0–3.0)1,2

–35%2.0

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red arrows indicate relative risk reductions (rrrs)

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References 1. Connolly SJ et al. N Engl J Med 2009; 361:1139–1151. 2. Connolly SJ et al. N Engl J Med 2010; 363:1875–1876 (letter to editor).3. Oldgren J et al. Dabigatran versus warfarin in atrial fibrillation patients

with low, moderate and hgh CHADS2 score: a RE-LY subgroup analysis. JACC2010; 55:A1.E2; presentation number 0903-04 (abstract).

4. Roskell NS.et al.Thromb Haemist 2011;104:1106-1115. 5. Hart RG et al. Ann Intern Med 2007; 146:857-867.

For Medical Professional Only

5 June 2012

Elvira Manzano

Increasing dialysis frequency and dura-tion may improve overall health and sur-

vival in patients with renal failure compared with conventional dialysis, four studies have found.

In one study involving 11,000 patients, the risk for all-cause mortality was 13 percent lower in patients who received daily home hemodialysis compared with those on tradi-tional thrice weekly in-center regimens (HR 0.87, 95% CI 0.78-0.97). [J Am Soc Nephrol 2012; DOI:10.1681/ASN.2011080761]

The finding was supported by another study demonstrating a 45 percent reduction in mortality for patients receiving intensive dialysis (five sessions a week, each session lasting 7 hours) compared with those on conventional dialysis (HR 0.55, 95% CI 0.34-0.87). [J Am Soc Nephrol 2012; DOI:10.1681/AS.2011070676]

In the 420-patient study, 6.1 deaths per 100 person-years were seen in the intensive group versus 10.5 deaths per 100 person-years in the conventional group.

“We found that intensive home dialysis is associated with markedly improved patient survival compared with conventional in-center dialysis,” said study author Dr. Gihad Nesrallah, from the London Health Sciences Center in London, Ontario, Canada. “But whether this relationship is causal remains unknown.”

The authors noted that patients may find home dialysis more appealing because of less

dietary restriction, flexible scheduling and lower cost.

Meanwhile, another study of 2,800 patients showed that maintaining the thrice a week schedule but extending the sessions to a mean of 7.85 hours during overnight clinic stays provided better mortality outcomes than conventional dialysis. Patients who opted for nocturnal hemodialysis showed a 25 per-cent reduction in 2-year mortality risk com-pared with matched controls. (HR 0.75, 95% CI 0.61-0.91; P=0.004). [J Am Soc Nephrol 2012; DOI:10.1681/ASN. 2011070674]

Overnight dialysis also resulted in reduced weight, lower systolic blood pressure and blood phosphorous levels.

“Conversion to in-center nocturnal hemo-dialysis (INHD) was associated with favor-able laboratory markers with significantly lower serum phosphorus despite improved

More intensive dialysis improves patient outlook

Several studies suggest that increasing the frequency and duration of dialysis may improve the prognosis of patients with renal failure.

6 June 2012

or stable nutritional status,” said the authors, led by Dr. Eduardo Lacson, Jr. from the Fre-senius Medical Care North America, Massa-chusetts, US. “This study supports the notion that therapy with INHD is a viable alternative dialysis regimen.”

In the final study, Dr. John Daugirdas from the University of Illinois, Chicago, US and colleagues, showed that six times a week of dialysis decreased patients’ serum phospho-rous levels compared with standard dialysis treatment. High-frequency dialysis also re-duced patients’ need for phosphorous low-ering medications. [J Am Soc Nephrol 2012; DOI:10.1681/ASN.2011070688]

“Frequent hemodialysis facilitates control of hyperphosphatemia and extended session lengths could allow more liberal diets and freedom from phosphorous binders,” the au-thors said.

Thrice-a-week dialysis, lasting 4 hours per treatment, is the standard protocol for end-stage renal disease at most dialysis centers. Extended intervals between dialysis sessions maybe preferred by patients. However, this poses risks as the less frequent the dialysis ses-sions, the greater the gradient between peak and trough solute and water levels.

Commenting on the studies, Dr. Elizabeth Oei, associate consultant at the department of renal medicine, Singapore General Hospital, said frequent or longer dialysis is associated

with many benefits, but the association with improved survival requires further analysis. “Daily hemodialysis is more efficient with respect to solute clearance and better blood pressure control. Of note, increased clearance of waste products from the blood has not been shown to improve survival in a key landmark study on dialysis patients (HEMO study).”

Compared with conventional dialysis, fre-quent or longer dialysis is however more ef-ficient at removing phosphate, she said. “Pa-tients can benefit from reduced pill burden and superior phosphate control.”

Oei noted that despite growing demand, hemodialysis remains a limited resource. She said frequent dialysis is not routinely pre-scribed due to lack of dialysis resource and unfavorable response from patients with re-gard to increasing time attached to the ma-chine. The procedure is expensive and cur-rently, there is no support for subsidized home dialysis programs.

“Despite government support, dialysis is still a significant burden to patients who elect to suffer the complications of untreated end stage renal failure than burden their family with long term hefty medical bills,” Oei said.

“Until we can meet the basic dialysis re-quirements of the underprivileged, frequent and prolong dialysis may be regarded as a luxury rather than a necessity,” she conclud-ed.

7 June 2012 Forum

Singapore’s healthcare system is facing challenges similar to many other countries

in Asia. Our population has grown fast – by 25 percent over the past 10 years. We are also aging rapidly. By 2030, one in five Singapore residents will be aged 65 and above. With increasing life expectancy and changing life-styles, we are faced with a growing burden of chronic diseases. As we plan for the future, we must recognize that economic cycles will be increasingly volatile. That’s why more of the same will not do. We need to fundamen-tally re-examine how healthcare services are structured and delivered.

Effective chronic disease management will require new models of care, especially within the community. This will help reduce sub-sequent costly complications. Therefore, we have been shifting our focus from episodic care in acute hospitals to a more holistic ap-proach.

The holistic approachOver the past year, we have been develop-

ing integrated care pathways for five com-mon clinical conditions: chronic obstructive pulmonary disease (COPD), diabetes, heart failure, stroke and hip fracture. The aim is to chart out the care that patients should receive across the continuum of care from prevention to end-of-life care.

For each condition, a workgroup of local clinical experts will identify and prioritize clinical interventions based on latest clinical

Health minister outlines future challenges

Excerpts from a speech by Singapore health minister Mr. Gan Kim Yong during the ‘Health-care in Asia 2012’ conference held in Singapore recently.

evidence to determine the value and cost-ef-fectiveness of each intervention, and the types of patients most likely to benefit from it. The workgroup will then determine when, where and how the prioritized services should be delivered and will also identify enablers, such as IT systems that are required to deliver the services effectively and efficiently. A perfor-mance framework for each pathway is also underway to ensure that the identified inter-ventions are consistently delivered to the ap-propriate patients.

We have invested heavily in building acute hospitals and they have attained high stan-dards of care, with some earning internation-al recognition for excellence. We now need to focus on prevention to reduce avoidable ad-missions.

Everyone recognizes the need to live healthy lives. But translating this knowl-edge into sustained action is a challenge. The Health Promotion Board (HPB) is leading the strategic shift in health promotion by moving from the traditional awareness campaigns to the creation of social movements, rallying the community to co-create and own grassroots level initiatives, customized for their respec-tive local communities.

Promoting healthOur aim is to create a health-promoting

ecosystem where healthy living is the new norm. To this end, the HPB aims to recruit an army of 10,000 Health Ambassadors to advo-

8 June 2012 Forumcate healthy living among their peers. To date we have recruited more than 2,000 and their impact is already being felt.

HPB’s Integrated Screening Program (ISP) is one example of this ecosystem in action. It encourages Singaporeans to be screened for obesity, diabetes, high blood pressure, high cholesterol and for selected cancers, as well as to encourage follow-up and management.

Under the ISP, Singaporeans who turn 40 will receive invitations from HPB to go for the recommended screening tests based on age and gender. The program has now been enhanced to include the screening of seniors for functional decline.

Patients with abnormal results are referred to a network of GPs to ensure that they are ap-propriately followed up. Health ambassadors will encourage those who should be screened to come forward and also to organize local healthy lifestyle events.

Since 80 percent of primary care is pro-vided by private GPs, we have been working with them to introduce new models of care to better manage chronic diseases. To this end, family medicine clinics will be set up in the community with 4 to 6 GPs in each clinic, sup-ported by pharmacy and laboratory services, nurse educators and allied health profession-als.

We have also enhanced our Community Health Assist Scheme, a portable subsidy scheme for lower and middle income patients, so that they can enjoy subsidized care when they visit their GPs rather than rely solely on government polyclinics for subsidized treat-ment.

A range of home- and community-based aged care services will enable seniors to age in their communities, with support to fami-

lies in caring for their loved ones at home. We are working with the Ministry for Commu-nity, Youth and Sports to develop integrated facilities to provide day care for frail elderly, together with rehabilitation and dementia program for those who need more support.

Besides new care models, we are reorganiz-ing our healthcare system into regional health systems (RHS) to ensure integrated care. Each RHS would have an acute general hospital that works in close partnership with the pub-lic, private and people sector within the re-gion to provide seamless care for patients.

Eastern Health Alliance is one such RHS, which is anchored by an acute hospital (Chan-gi General Hospital) working in collaboration with Peacehaven Nursing Home, SingHealth Polyclinics and St. Andrew’s community hos-pital to enable patients to move seamlessly across care settings and receive appropriate care through shared clinical pathways.

Agency for integrated careSet up in 2008, the agency helps patients

navigate the healthcare system and refers them to the most appropriate care provider post-discharge, while a national electronic health records initiative ensures seamless ex-change of health information across the pro-viders.

But as our needs change, the framework will also need to evolve. We need to rein in costs by reducing inefficiencies and discour-aging over-consumption. We are judicious in deciding what to subsidize. Not all that is new is better and thus not all new services would be subsidized. Singapore’s healthcare system is very much a work in progress. While we have our successes, we also have our chal-lenges.

9 June 2012 Singapore Focus

One shot of the recently approved IVF drug corifollitropin alfa (Elonva®, Mer-

ck Sharp & Dohme) achieved a 38.9 percent ongoing pregnancy rate among women undergoing in vitro fertilization (IVF) com-pared with 38.1 percent for those treated with a standard 7-day regimen consisting of daily injections of recombinant follicle stim-ulating hormone (rFSH), in a randomized non-inferiority trial of 1,506 women. [Human Reprod 2009;24:3063-3072]

“Simplifying fertility treatment with new modalities of treatment and new medication may encourage more infertile couples to embark on treatment earlier...” said Dr. Loh Seong Feei, medical director of the Thomson Fertility Centre.

He said about 1 in 7 couples in Singapore experience infertility. About 5,000 IVF proce-

dures were performed in Singapore in 2011, up from under 2,000 in 2004, according to data from the Ministry of Health.

The new drug’s cost is similar to that of standard therapy and the overall cost of IVF would remain unaffected, which Loh said is about $10,000 per cycle in Singapore.

Fewer injections needed with new IVF drug

Listening to music, even for short periods each

week, may have therapeutic potential in elderly patients with depression, according to research conducted in Singapore.

The randomized controlled trial found that patients who listened to music for 30 min-utes per week for 8 weeks had lower depres-sion level compared with those who did not. [J Clin Nurs 2012;21:776-83]

“We found that depression levels reduced weekly in the music group, indicating a cu-mulative effect, and a statistically significant

reduction in depression levels was found over time in the music group,” said lead study author Dr. Moon Fai Chan, assistant professor in the Alice Lee Centre for Nursing Studies, National University of Singapore.

Depression is a common psychiatric dis-order in the elderly.

“Music is an inexpensive therapeutic method of improving life quality in commu-nity-dwelling older people in this study,” said the authors.

Conventional pharmacological method might result in dependence and impairment in psychomotor and cognitive functioning, they added.

Music reduces depression in elderly


Singapore scientists have identifi ed more than 600 genes that are mutated in pa-

tients with stomach cancer, paving the way for treatments tailored according to the ge-netic make-up of individual stomach tu-mors.

A research team from Duke-NUS Gradu-ate Medical School and the National Cancer Center Singapore found two genes – FAT4 and ARID1A – to be mutated in 5 and 8 per-cent of about 100 stomach tumors, respec-tively.

Furthermore, manipulation of FAT4 and

ARID1A function in the lab altered the growth of stomach cancer cells.

“More research is required to realize the clinical implications of these findings. ARID1A and FAT4 are likely also involved in many other cancer types, not just stom-ach cancer,” said senior author associ-ate professor Patrick Tan of the cancer and stem cell biology program at Duke-NUS. His research team is now working on translating the results of this study into clinical applications. [Nature Genetics 2012; DOI:10.1038/ng.2246]

Scientists identify stomach cancer genes

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Rajesh Kumar

Scientists at A*STAR’s Institute of Bioengi-neering and Nanotechnology (IBN) have

developed a cheaper, faster and more efficient platform for preclinical drug discovery appli-cations.

They have created a chip sized multi-chan-nel microfluidic perfusion platform which can grow and monitor the development of various tissues and organs in several zebraf-ish embryos simultaneously to test drug tox-icity. [Lab Chip 2012;12:892-900]

Called ‘Fish ‘n Chips’, the miniature de-vice can be used as the first step in drug screening during the preclinical phase to complement existing animal models, said IBN group leader Professor Hanry Yu.

Toxicity is a major cause of drug failures in clinical trials and zebrafish embryos are an important model for toxicity testing. The morphological and molecular basis of tissue and organ development in zebrafish embry-os resemble that of humans, and the overall drug toxicity is also comparable with that observed in animals.

In contrast to animal models, zebrafish are inexpensive, easily obtainable in large quan-tity, readily accessible immediately after fertilization, require a shorter development time, and are cheaper to maintain.

The current drug studies performed on traditional microtiter plates do not allow perfusion or the replenishment of growth media and drugs. The plates cannot facilitate live imaging either, as the zebrafish embryos are not fixed in one position due to the size of the well, said the researchers.

Fish ‘n Chips for faster drug development

Visualizing tissues and organs in embryos is cumbersome. It involves first mounting the embryos in a viscous medium such as gel, and then manually orienting the embry-os using fine needles. The embryos also need to be anesthetized to restrict their movement and saline continuously applied to prevent them from drying. These additional precau-tions can further complicate the drug testing results, they said.

The ‘Fish ‘n Chips’ microfluidic platform comprises a row of eight fish tanks, each one over 200 times smaller than the individual well of a microtiter plate, in which embryos are placed and covered with an oxygen per-meable membrane.

The unique diagonal flow architecture of the tiny device allows the embryos to be con-tinually submerged in a uniform and consis-tent flow of growth medium and drugs, and the attached gradient generator can dispense different concentrations of drugs to eight

The fish tank for holding zebrafish embryo is 200 times smaller than a well in a microtiter plate.

12 June 2012 Singapore Focusdifferent embryos simultaneously for dose-dependent drug studies.

The dimensions of the fish tank can be customized to fit the embryos exactly in the tank and restrict their movement for live im-aging. This is crucial to monitor the growth and development of the various tissues and organs in the embryos.

Researchers at the IBN have been able to successfully observe the development of var-ious organs such as the eyes, ears, melano-phores, brain, yolk sac, trunk and chorion, as well as heartbeats in the zebrafish embryos, using high-resolution bright-field and fluo-rescence imaging.

Using ‘Fish ‘n Chips’, they also conducted drug toxicity testing of valproic acid (VPA), a drug which causes birth defects if con-sumed by women during their pregnancy.

VPA caused abnormality in the development of the eyes and tail in the embryos.

The findings established the proof-of-con-cept that the device could be used as an or-gan-level drug screening model. The design of the platform can be modified to accommo-date more zebrafish embryos, as well as the embryos of other animal models.

“Miniaturization is being explored in various ways by our researchers to revolu-tionize drug development and disease di-agnosis. This microfluidic platform enables researchers to cut down the time and cost of drug testing significantly, said IBN ex-ecutive director professor Jackie Ying while offering the technology for licensing to companies.

“We are also open to collaboration to de-velop customized assays for drug testing.”


Elvira Manzano

Postmenopausal women at high risk of osteoporotic fractures should seek early

medical attention to decrease their risk of having vertebral, hip and non-vertebral frac-tures, the Osteoporosis Society of Singapore (OSS) has urged.

“Osteoporotic patients whose bone density has begun degenerating require medication to prevent disease progression. Drinking milk, eating cheese and getting enough sun in the morning, while good for bone health, may not be sufficient in women with bone degener-ative condition,” said Professor Lau Tang Ch-ing, senior consultant, rheumatology division, National University Hospital, and president of OSS.

Latest data from the Ministry of Health showed that Singapore has the highest num-ber of osteoporotic fractures in Asia. Given this alarming information, Lau said it is essential that postmenopausal women take two clini-cal risk estimation tests for osteoporosis – the Osteoporosis Self-Assessment Tool for Asians (OSTA) and the FRAX® – and discuss the re-sults with their doctors to see whether they need to undergo bone mineral density (BMD) screening or consider medical therapy.

The OSTA test uses a woman’s age and weight to identify patients at increased risk of

Experts sound alarm over osteoporotic fractures

osteoporosis while the FRAX® tool calculates her 10-year fracture risk.

Professor Leong Keng Hong, consultant rheumatologist at Gleneagles Medical Cen-tre, and adjunct associate professor at the Yong Yoo Lin School of Medicine, National University of Singapore, said those with high risk scores on OSTA or FRAX need more than lifestyle changes. “They need as-sessment and medications to improve their bone health and prevent fractures,” he said. “Without medications, the risk of fractures doubles or increases up to four times.”

Whether patients opt for oral medications, intravenous infusions, or subcutaneous injec-tions, Leong said compliance with prescribed medication is important to prevent the first fracture or further fractures.

Studies showed that one in five patients die within the first year after a hip fracture due to complications such as deep vein thrombosis (DVT), pneumonia or pulmo-nary embolism. More than half of those who survived would end up bedridden or wheel-chair bound and would need assis-tance to mobilize. Vertebral fractures may have smaller impact on mortality, but can lead to severe chronic pain of neurogenic origin and deformity.


Elvira Manzano

A nationwide campaign has been launched in Singapore to raise funds for athletes

with intellectual disabilities and raise aware-ness of their capabilities.

The “Thank You Mom,” campaign is a partnership project between P&G and NTUC Fairprice and will benefit at least 8,000 ath-letes from Special Olympics Singapore.

Special Olympics is a global movement led by athletes with intellectual disabilities who use sports to showcase their capabili-ties and build tolerant communities. For over 29 years, Special Olympics Singapore is the only organization in the country that has been providing free training and helping persons with intellectual disabilities to par-ticipate in sports. However due to limited resources, the organization relies heavily on donations to fund its many projects.

Under the “Thank you Mom” campaign, athletes from Special Olympics Singapore will get a portion of the sales of selected P&G brands purchased at NTUC Fairprice stores. Part of the proceeds from the campaign, which ran until April 30, will be used to train and send athletes to a soccer tournament in Singa-pore in September and an ice skating competi-tion in Pyongyang, Korea in 2013.

In the last World Summer Games in Ath-ens, Greece, Special Olympics Singapore was able to bring home 12 gold medals, 13 silver medals and 12 bronze medals.

“Having interacted with the athletes of Special Olympics, we realize that what the organization does on a daily basis is very

Fund-raising campaign for athletes with special needs

meaningful in developing the lives of these athletes with special needs. We hope to gen-erate greater awareness and to share with Singaporeans what a great cause this collab-oration supports,” said Ms Ellie Xie, coun-try manager, P&G Malaysia and Singapore. “With this, P&G hopes to bring about social change through sports and help make Singa-pore a place that further embraces individu-als with intellectual capabilities.”

She said P&G will be donating $25,000 to Special Olympics Singapore or a total of $250,000 to Special Olympics in Asia spread over Malaysia, Thailand, Vietnam and Sin-gapore to increase public awareness for athletes with special needs and help them achieve their sporting goals.

To be eligible to join Special Olympics, athletes must be at least 8 years old, with in-tellectual disability, cognitive delays as mea-sured by intelligence quotient (IQ) testing, or significant learning or vocational problems due to cognitive delay that requires specially designed instruction.

Ellie Xie, country manager, P&G Singapore and Malaysia (4th from left) and Seah Kian Peng, chief executive officer, NTUC Fairprice (6th from left), announce their commitment to raise awareness for Special Olympics ath-letes. At far right is Dr. Teoh-Koh Sock Miang, president of Special Olym-pics Singapore.


Lutein crucial for early cognitive developmentRajesh Kumar

Millions of children under five years of age fail to reach their full cognitive po-

tential each year, mainly due to lack of ad-equate nutrition essential for development during the early years of life.

While the role of iron, iodine, choline, zinc and omega-3 fatty acids is well established, lutein is now being acknowledged as another important nutrient crucial in the early cogni-tive development, said Dr. Elizabeth Johnson, research scientist at the Jean Mayer USDA Hu-man Nutrition Research Center on Aging at Tufts University in Boston, Massachusetts, US.

Johnson cited her study involving the ex-amination of brain tissues of 30 healthy in-fants who had died in the first year of their lives due to sudden infant death syndrome (SIDS) and other reasons.

“We found that lutein is not only present in all the four regions of the infant brain (frontal cortex, hippocampus, auditory cortex and oc-cipital cortex), but it is there in preference to other carotenoids,” she said. Lutein is an inte-gral part of the eye’s retina too.

Also, 60 percent of all carotenoids in the infant brains turned out to be in the form of lutein. This proportion was double than what earlier studies have found in the adult brains. Researchers found this level of concentration surprising, considering only a sixth of all the carotenoids found in the human diet are usu-ally in the form of lutein.

If the brain is soaking it up from across the blood-brain barrier and accumulating it, clearly it is needed for something, said profes-

sor Sanja Kolaček, professor of pediatrics at the Children’s Hospital Zagreb, Croatia and the vice-president of the Croatian Pediatric Society.

Lutein is only available through dietary sources and cannot be made by the body. Therefore, women of child bearing age and expectant and breastfeeding mothers should be encouraged to eat a wide variety of foods as part of a balanced diet, including lutein-rich foods such as green, leafy vegetables and eggs, said Kolaček.

For infants, breast milk is the best source of lutein and breast feeding exclusively for up to six months can prevent a lot of problems in them, including growth issues such as the child growing too fast, or not growing fast enough. Supplementing breast feeding with other foods is usually recommended no earlier than four months and no later than six.

“Where mothers need to provide a formula at any age during the first year of the child’s life, [fortified formula] is the right option compared to cow’s milk,” she added.

“Cow’s milk should not be the infant’s ba-sic diet as it does not provide all the nutrients necessary for the child’s physical and cogni-tive development.”

Kolaček said doctors should never rec-ommend elimination diet to prevent a dis-ease. If a woman or child needs to eliminate nuts, dairy products, fish or eggs due to a health condition, they should try to substitute the nutrients they might be miss-ing out on.

Both Johnson and Kolaček were recently hosted in Singapore by Abbott Nutrition.


Feeding difficulties can persist into adulthoodRajesh Kumar

Feeding difficulties can have a lasting

impact on a child’s phys-ical and mental develop-ment and the condition can persist into adoles-cence and adulthood if not treated early, accord-ing to an expert.

Dr. Glenn Berall, chief of pediatrics at North York General Hospital in Toronto, Ontario, Canada and a leading expert on the subject, cited a study that looked at children di-agnosed with feeding dif-ficulties at age one or two, followed them up at nine years of age and compared them with their classmates who did not have such prior diagnosis.

The researchers found that prevalence of feeding difficulties was three times as high in children with prior diagnosis. Recent studies also support the idea that the condition per-sists if not addressed early, said Berall. He was hosted in Singapore recently by Abbott Nutrition and spoke to GPs and pediatri-cians about his experiences.

While habitually picky eaters who are otherwise well nourished are not a concern, eating difficulties become troublesome when they cause consequences, be they nutritional (iron and calcium deficiency), developmen-

tal or emotional and behavioral. Studies have shown that children who have feeding prob-lems have a higher prevalence of depression, anxiety and delinquency, Berall said.

About 20 to 30 percent of all children are believed to have some level of feeding diffi-culty, and the rate is up to 80 percent in those with autism and other neuro-developmental problems.

Being the first line of care, GPs will be the first ones to encounter these cases. They usu-ally check the level of severity, sub-category that the condition falls into and the level of parental anxiety associated with the child’s feeding problems, Berall said.

About 20 to 30 percent of all children have some level of feeding difficulty.


Some doctors use the diagnostic toolkit called Identification and Management of Feed-ing Difficulties (IMFeD) to identify and man-age the condition themselves or to refer the child to a specialist. The kit classifies common feeding difficulties as: limited appetite, sen-sory food aversion, underlying medical condi-tion, fear of feeding, neglect and undue care-giver concern. Berall said common caregiver styles (controlling, responsive, neglectful and indulgent) also need to be understood before deciding on the right treatment approach.

Some children will do well with the food rules (see box). The highly selective eaters are afraid of trying new foods and can re-spond well to spicy foods, whereas the more serious ones will require a longer work up.

While parents and GP work together to resolve the issue, adding a balanced supple-ment such as PediaSure to the child’s diet won’t suppress their appetite or interfere with feeding, added Berall. Instead, it could help recover their growth and relieve the parents’ anxiety by providing reassurance that their child is getting better nutrition.

“That will help parents follow the food guidelines to make sure the whole treatment package is a success,” he said. Children with high selectivity and fear of feeding also take a long time to respond. Adding a supple-ment to their diet, given at the end of the day, will help balance their nutrition in the mean-while.

The food rules• The parent decides where, when, and

what the child eats, but the child de-cides how much is eaten.

• Avoid distraction at mealtime. Use a high chair to help confine the toddler to the feeding environment.

• Avoid juice and milk and provide only water for thirst

• Do not get overly excited or animated (eg, flying airplanes into the mouth).

• Eating should begin within 15 min-utes of the start of the meal and last no longer than 30-35 minutes.

• Do not cook at short notice to pander to the child’s whim.

• Respect the child’s tendency to “neo-phobia” and offer a food repetitively before giving up on it.

• Encourage independent feeding: The toddler should have his or her own spoon.


Singapore Events13/6/12GP-CME Refractive Surgery – Lasik Info : National Healthcare Group (NHG) PolyclinicsTel : +65 6355 3000Website : www.nhg.com.sg/events.asp?eventgroup=4

14/6/12GP-CME Management and Referrals of Common Skin Conditions Info : National Healthcare Group (NHG) PolyclinicsTel : +65 6355 3000Website : www.nhg.com.sg/events.asp?eventgroup=4

28/6/12GP-CME Early Detection and Management of Lung Cancer Info : National Healthcare Group (NHG) PolyclinicsTel : +65 6355 3000Website : www.nhg.com.sg/events.asp?eventgroup=4

28/6/12GP-CME Developmental Screening Info : National Healthcare Group (NHG) PolyclinicsTel : +65 6355 3000Website : www.nhg.com.sg/events.asp?eventgroup=4

3/7/12GP-CME Management and Referrals of Common Skin Conditions Info : National Healthcare Group (NHG) PolyclinicsTel : +65 6355 3000Website : www.nhg.com.sg/events.asp?eventgroup=4

5/7/12GP-CME Dementia Info : National Healthcare Group (NHG) PolyclinicsTel : +65 6355 3000Website : www.nhg.com.sg/events.asp?eventgroup=4

19 June 2012 News

Higher risk of stroke in older women diagnosed with AF

Rajesh Kumar

Elderly women had a higher risk of stroke than men following a recent diagnosis of

atrial fibrillation (AF), regardless of their oth-er risk factors and use of warfarin, a study has found.

The findings suggest that current antico-agulant therapy to prevent stroke might not be sufficient for older women, the research-ers said while urging clinicians to apply new strategies to effectively prevent stroke equally in men and women. [JAMA 2012;307:1952-1958]

All patients with AF have a 5-fold increase in the risk of stroke compared with the general population; therefore, antithrombotic agents are prescribed to reduce this risk. Under-uti-lization of these agents in elderly women is believed to contribute to an even higher risk in these patients.

Researchers used administrative databas-es linking to hospital discharge summaries, physicians’ records and prescription drug claims database for 39,398 men (47.2 per-cent) and 44,115 women (52.8 percent) aged 65 years or older, who were admitted to hos-pital with recently diagnosed AF in Quebec, Canada from 1998 to 2007.

At admission, women were older and had a higher CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes mel-litus, prior stroke or transient ischemic at-tack) score than men (1.99 vs. 1.74, P<0.001). At discharge, women appeared to fill more

warfarin prescriptions compared with men (odds ratio, 1.07 [95% CI, 1.04-1.11]; P<0.001) and adherence to warfarin treatment was good in both sexes.

Crude stroke incidence was 2.02 per 100 person-years (95% CI, 1.95-2.10) in women vs. 1.61 per 100 person-years (95% CI, 1.54-1.69) in men (P<0.001). The sex difference was mainly driven by the population of patients 75 years or older. In multivariable analysis, women had a higher risk of stroke than men (adjusted hazard ratio, 1.14 [95% CI, 1.07-1.22]; P<0.001), even after adjusting for baseline comorbid conditions, individual components of the CHADS2 score, and war-farin treatment.

Analysis indicated that women had a 14 percent higher risk of stroke than men, after adjusting for various factors. But the authors could not figure out why.

“[It] may be attributable to physiology (such as uncontrolled hypertension), vascular biology, genetic factors, hormonal or throm-boembolic factors, or psychosocial factors that differ between men and women. We were not able to identify these factors with our da-tabase,” said author Dr. Meytal Avgil Tsadok of the McGill University Health Center, Mon-treal, Canada, and colleagues.

“Although epidemiologic studies have investigated sex differences in stroke occur-rence, little is known about warfarin effec-tiveness between men and women in the real-

20 June 2012 Newsworld clinical setting. Our results suggest that elderly women with AF may need to be targeted for more effective stroke prevention therapy.”

Associate Professor Tan Ru San, senior consultant in the department of cardiology and director of clinical trials at the National Heart Centre Singapore, agreed saying the recent European AF management guidelines already advocate the use of a new stroke risk score (CHA2DS2-VASc) that assigns higher

risk to female patients with AF, compared with males.

“This current study confirms the obser-vation in several prior studies that stroke rates are higher in women with AF. In addi-tion, it demonstrates that the increased risk in women is most pronounced in elderly patients aged 75 years or more, regardless of their risk profile and use of anticoagula-tion,” said Tan.

21 June 2012 Conference Coverage

Smoke-free cities – A step towards healthy environments

Dubai, host of the 2012 World Congress of Cardiology, has zero-tolerance poli-

cies on drink-driving and drugs, but not for smoking.

Though smoking is banned in many pub-lic offices and places such as shopping malls, there are designated smoking areas all over the city. The ban is not difficult to observe even for the most addicted smokers. That is the situation in Dubai, and in many cities around the world.

A report by the World Health Federation showed that over half of the world’s total population of 6.7 billion lives in an urban setting. Three out of five people will live in cities by 2030. While city living offers more opportunities, greater access to health care facilities, and governance, the conditions in an urban setting can also amplify problems. Many of today’s sprawling cities face a tri-ple burden of infectious diseases, waves of accidents, injuries and violence, and chronic diseases with the globalization of unhealthy lifestyle practices such as heavy drinking, physical inactivity and smoking.

Interestingly, smoking prevalence is high-est in urban areas. An estimated 600,000 in-dividuals worldwide died from second-hand smoke in 2011, and 75 percent of these deaths were among women and children. We see the impact of second-hand smoke as people live together in closer environments. Accord-ing to Dr. Sidney Smith, World Health Fed-

eration presi-dent, where a person lives in t r ins ica l ly affects their health and life options.

The harm-ful effects of smoking – heart attack, stroke and p r e v e n t a b l e deaths – speak for themselves in many ways. What can we do to advo-cate for smoke-free cities around the world? We should raise public awareness to bring statistics to a much broader audience. Urban areas can be built, organized, managed, retrofitted and governed in ways that promote health.

The number of people protected by com-prehensive smoke-free laws has doubled from 2008 to 2010. Nearly 3.8 billion people live in countries with some kind of anti-smoking measure; 11 percent of the world’s population are protected by national smoke-free laws. Some cities have taken incremen-tal steps and acted as catalyst for develop-ing smoke-free environments. Restaurants

Excerpted from a presentation by Mr. Chris Gray, senior director, International Public Affairs, Pfizer, during the World Congress of Cardiology Scientific Sessions 2012, held recently in Dubai, UAE.

Dubai, like many cities around the world, has banned smoking in public places.

World Congress of Cardiology Scientific Sessions 2012, 18-21 April, Dubai, UAE


worldwide are going smoke-free. We can see it in the Americas and in Southeast Asia. Article 8 of the WHO Framework Convention on Tobac-co Control (FCTC) has become the basis for cities developing smoke-free legislation.

Moscow has no national smoke-free leg-islation and sub-national jurisdictions have no authority to adopt and implement smoke-free laws. While Manila has national laws regulating smoking in public places, strict implementation remains a problem. Mexico City set an example for the world when it enforced a comprehensive smoke-free law in 2008. The hospitality industry – restaurants and bars – went up against it and argued that the smoking ban will harm economic inter-ests, employment and productivity. How-ever Mexico’s experience, as well as Hong Kong’s, suggest otherwise.

New York City made a tremendous move when it raised the tobacco tax in 2002 and in-stituted a smoking ban in all bars, clubs and restaurants in the city in 2003. As a result, the number of smokers dropped by 300,000 – a reduction that could save 100,000 lives. The ban has been extended to include public golf courses, sports grounds, beaches and plazas. So far, in 2012, 108 tickets have been issued for smoking violations.

In the UK, the Liverpool City Council voted to pursue a local act of Parliament to make the city smoke-free became instrumen-tal in the passage of a national smoking leg-islation in 2006. This demonstrates the strong role municipal leaders play to drive national agendas and policies. Activism really has a profound impact on government.

In Nueva Vizcaya, a province in the north of Philippines, serious implementation of smoke-free ordinances dramatically reduced tobacco use and exposure to second hand-

smoke in homes, workplaces and on public transportation. A city with a tobacco planta-tion and 400,000 inhabitants succeeded in in-stituting anti-tobacco measures.

China, home to one-third of the world’s smokers, outlawed smoking in buses, restau-rants and bars starting in May 2011. Russia plans to implement a similar measure begin-ning in 2015.

In the Middle East, where waterpipe to-bacco smoking is a concern, heart experts have emphasized the need to direct resourc-es to prevention strategies to fight heart dis-ease. Saudi Arabia has long-declared the holy cities of Mecca and Medina as smoke-free. Last February, Kuwait imposed a blan-ket ban covering all forms of smoking in all indoor public places, except in shisha par-lors, to protect public health.

Acknowledging the ill-effects of tobacco on health, heart societies in Asia went a step further and took on the challenge to become leaders in tobacco control at the recent World Conference on Tobacco or Health 2012 (WC-TOH) held recently in Singapore. Twenty-one country representatives and 16 heart foundations established advocacy priorities all targeted at making Asia Pacific smoke-free by 2040. The move is a major step for-ward and adds momentum to the growing smoke-free movement across the globe.

“Tobacco use is not just a problem for in-dividual people or nations; it is a collective health responsibility for mankind,” said Dr. Wael Al Mahmeed, board member, Emir-ates Cardiac Society, which collaborated on the bid to host the 2015 World Congress in Abu Dhabi. “In years to come, we want Abu Dhabi 2015 to be remembered as the place where the world collectively said: ‘enough is enough’.”


Personalize CVD prevention for women

Radha Chitale

Cardiovascular disease prevention is im-portant among women but the ideal ap-proach, which includes personalized risk stratification and assessment, is not reflected in current risk assessment models.

“The global risk assessment tools that we use today – they don’t care about the dynamic nature of risk factors within individuals and populations,” said Dr. Dilek Ural, Department of Cardiology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey. “It is impossible with these tools to evaluate temporal lifelong changes in individuals.”

More than 8.6 million women die of CVD yearly but their risk of cardiac morbidity or mortality is underestimated.

Women often present with heart disease differently than men do. While major risk fac-tors for heart disease and stroke are similar between men and women, many of the non-major risk factors differ.

Hypertension, diabetes, psychological stress and lack of physical activity are more important determinants of CVD in women.

Additionally, these risk factors are distrib-uted with significant differences through-out the world. For example, high cholesterol is a major problem among women in North America, Europe and Australia. High blood pressure is a common contributor to CVD among African women, and diabetes and obesity are the culprits among women in the Middle East.

The American Heart Association made an important amendment to their guidelines in 2011 by changing the criteria for risk status from a 10-year coronary heart disease event risk of 20 percent to a 10-year cardiovascular disease event risk of 10 percent.

This change was the result of studies show-ing women are more prone to stroke as a result of heart disease and may present with disease about 10 years later than male counterparts.

Ideally, Ural said cardiovascular preven-tion and assessment tools should incorpo-rate genetic factors, vascular age, lifelong exposure to multiple risk factors and country-based socioeconomic factors in order to per-sonalize risk stratification and management for women.


Over 8.6 million women die of CVD each year around the world.


Salt tax lowers CV mortalityRadha Chitale

Reducing daily salt intake via voluntary salt reduction in industrially processed foods

or through a tax on high-salt foods may help cut cardiovascular disease mortality, according to preliminary research conducted in the US.

“Elevated blood pressure is the leading risk factor for death globally,” said lead researcher Dr. Thomas Gaziano of the Harvard School of Medicine, Boston, Massachusetts, US. “Salt is associated with increased blood pressure in cardiovascular disease.”

Gaziano and colleagues also sought to re-duce the economic burden of hypertension while improving quality and quantity of life through low-cost salt reduction methods.

This type of approach could be important in low- and middle-income countries and the fast-developing BRIC (Brazil, Russia, India, China) nations where hypertension is poorly controlled, if it is diagnosed at all.

The World Health Organization and other global agencies recommend a daily salt in-take of 5 grams or less. The mean daily salt intake in BRIC countries is 10 grams. In some countries, daily salt intake exceeds 16 grams.

The researchers modelled the efficacy and financial viability of reduced salt intake through a voluntary 9.5 percent decrease in the salt content of manufactured foods and a 40 percent tax on salty foods, similar to a to-bacco tax. Similar models have been used in the UK.

Both methods reduced daily sodium intake but voluntary salt reduction was more effec-tive with a 10 percent decrease in sodium in-

take. The salt tax led to a 6 percent decrease. Although some mean daily salt intake re-

mained over the recommended value, Gazia-no said both approaches would lead to about a 3 percent reduction in the rate of cardiovas-cular death and save costs by reducing the number of treatments for heart attacks and stroke.

For example, the incidence of heart attacks and strokes would fall by 1.7 percent and 4.7 percent in China, respectively, and by 1.47 percent and 4 percent in India.

The total cost for either method of salt re-duction was less than US$50 per person over their lifetime.

Gaziano estimated that high blood pres-sure accounts for about 10 percent of the global healthcare expenditure – about US$450 billion with up to a trillion USD expected over the next 10 years in new blood pressure-related events such as stroke and heart attack, not including the cost of lost productivity due to absence from work or early death.

“Even modest reductions in salt consump-tion could lead to improvements in CVD mor-tality and save overall healthcare costs,” he said.

A separate model emphasizing improved screening and treatment for high-risk hyper-tensives whose systolic blood pressure was over 140 and whose 10-year cardiovascular event risk was over 20 percent proved to be a more expensive but still cost effective method of reducing cardiovascular fatalities by about 3 percent in low- and middle-income countries.

The results of this preliminary study are expected to be published later this year.



Personal Perspectives

‘‘ My favorite topic at WCC was echocardiography during inter-vention. I was surprised that the session was ticketed because it was not mentioned on the website. It would have been bett er if ticketed sessions were highlighted on the website beforehand.

Dr. Amuthan Vivekanandan, cardiologist, India

There were a variety of presentations at this WCC – from basic science to interventional cardiology. Many sessions that I was interested in were concurrent and that made it diffi cult for me to att end.

Dr. Abdulwasea Derhim Alduais, cardiologist, Yemen

This is a well-organized conference, with lectures presented from many topics. It would have been more interesting if great-er emphasis was given to yoga and its ability to reduce stress.

Amandah Hoogbruin, professor of nursing, Kwantlen Polytechnic University-Surrey, British Columbia, Canada

This is my fi rst time att ending the WCC. It has been very reward-ing, both from the point of view of content and meeting people. I’m into public health and prevention, so I’ve been going to ses-sions on physical activity, tobacco control and nutrition.

Trevor Shilton, director of cardiovascular health, Heart Foundation of Australia, Perth, Australia

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India becoming CVD capital of the worldRajesh Kumar

India is acquiring the dubious distinction of being known as the diabetes and cardiovas-

cular disease (CVD) capital of the world, ac-cording to a US expert.

Professor Prakash Deedwania of the Uni-versity of California, San Francisco, US, was commenting on the findings of the Indian Heart Watch (IHW) study that assessed the country’s growing CVD epidemic and identi-fied reasons behind it.

The study found that lifestyle (physical activity, diet and smoking) and biological (obesity, diabetes, high blood pressure and el-evated cholesterol) risk factors for CVD were at higher levels in India than in developed re-gions such as the US and Western Europe.

Conducted between 2006 and 2010 and in-volving 6,000 men and women from 11 cities across India, it is the largest ever study prob-ing CVD risk factors in the country. It was led by Deedwania and Dr. Rajeev Gupta of Fortis Escorts Hospital, Jaipur, India.

While 79 percent of the polled men and 83 percent of the women were found to be physi-cally inactive, 51 percent of men and 48 per-cent of women were found to have high-fat diets. About 60 percent of men and 57 percent of women were found to have a low intake of fruit and vegetables, and 12 percent of men and 0.5 percent of women smoked.

“These results…must prompt the [Indian] government to develop public health strate-gies that will change lifestyles, if these risk factors are to be controlled,” said Deedwania.

As for the biological and metabolic risk factors, the IHW also found overweight and obesity in 41 percent of men and 45 percent of women. High blood pressure was reported

in 33 percent of men and 30 percent of wom-en, while high cholesterol was found in one-quarter of all men and women. Diabetes or metabolic syndrome was also reported in 34 percent of men and 37 percent of women.

Urban development is playing a role in the development of CVD risk factors, the IHW found. Smoking, high fat intake and low fruit/vegetable intake were shown to be more common in less developed cities, while physi-cal inactivity was seen to be more prevalent in highly-developed cities with their better transport networks.

Accordingly, metabolic risk factors such as obesity, high blood pressure and high cho-lesterol were seen to be more prevalent in highly developed cities that had easy access to cheaper fast foods/refined foods.

Even literate middle-class urban Indians had a low awareness and control of the CVD risk factors, the IHW study results showed. Of the approximately one-third of study par-ticipants found to have hypertension, only 57 percent were aware of their status, 40 percent were on treatment and only 25 percent had adequate blood pressure control.

In contrast, more than 75 percent of people with hypertension in high and middle-income countries are aware of their health status and more than 50–60 percent actually have their blood pressure under control.

“These results show that improving ur-ban planning and overall living conditions are critical to curb the CVD epidemic in In-dia,” said Gupta, adding that basic amenities, healthcare facilities and health literacy also needed to improve so people could take re-sponsibility for their own actions.



High-dose nicotine patch safe for heavy smokersRajesh Kumar

Smokers who have been smoking more than 40 cigarettes daily can be safely treat-

ed with a high-dose nicotine patch, according to Professor Richard Hurt, professor of medi-cine and director of nicotine dependence cen-ter at Mayo Clinic in Rochester, Minnesota, US.

Current dosing recommendations based on patient’s smoking rate suggest a dose of 7-14 mg/day for those smoking less than 10 ciga-rettes daily, 14-21 mg/day for those on 10 to 20 cigarettes daily, and 21-42 mg/day for smok-ers of 21 to 40 cigarettes daily. [Mayo Clin Proc 2000;75:1311-1316]

Hurt said the initial dose can be estimated on the basis of either the patient’s smoking rate or blood cotinine levels, and the adequa-cy of the nicotine replacement therapy (NRT) can be assessed either by patient response or by the replacement rate of blood cotinine. A higher percentage of blood cotinine replace-ment may increase patch therapy’s efficacy and improve withdrawal symptoms.

Nicotine gum, patch, lozenge, inhaler, bu-propion, varenicline and the combinations thereof can be used as first-line pharmaco-therapy, while clonidine and nortriptyline are suitable for second-line. Of these, the patch and varenicline and/or bupropion can be used as “floor” medications, along with short act-ing NRT products for withdrawal symptoms, said Hurt.

Patient involvement is the key to tobacco cessation and the selection of medicines and their doses should be guided by cardiologists’ clinical skills and knowledge of pharmaco-therapy, he added.

One study comparing 24-week extended therapy of transdermal nicotine patch dose of 21 mg/day with 8-week standard therapy showed a dose-response to patch therapy. [Ann Int Med 2010;152:144-151]


Smokers who have been smoking more than two packs of cigarettes a day may be safely treated with high-dose nicotine patches.

35 June 2012 Conference CoverageIn this 568-patient study, smoking absti-

nence was the same in the two groups by week 8. However, the extended therapy achieved a delayed relapse to smoking.

At week 24, extended therapy produced higher rates of point-prevalence abstinence (31.6 percent vs. 20.3 percent; [95% CI, 1.23 to 2.66]; P=0.002), prolonged abstinence (41.5 percent vs. 26.9 percent; [95%CI, 1.38 to 2.82]; P=0.001), and continuous abstinence (19.2 percent v 12.6 percent; [95% CI, 1.04 to 2.60]; P=0.032) versus standard therapy.

Extended therapy also reduced the risk for lapse (hazard ratio, 0.77 [95% CI, 0.63 to 0.95]; P=0.013) and increased the chances of recovery from lapses (hazard ratio, 1.47 [95% CI, 1.17 to 1.84]; P=0.001). At week 52, extended therapy produced higher quit rates for prolonged abstinence only (P=0.027). No differences in side effects and adverse events between groups were found at the extended-treatment assessment.

In a randomized placebo-controlled trial involving varenicline therapy in 714 smok-ers with stable cardiovascular disease, patch therapy achieved 47 percent abstinence, com-pared to 14 percent on placebo (95% CI 4.18-8.93). [Circ 2010;121:221-229]

Citing the case study of a 58-year-old smoker with chest pain who was put on two 21mg patches every morning, Hurt said a follow-up phone call 2 weeks later revealed he was experiencing cravings for cigarettes in the evenings, which had increased his use of reliever nicotine inhaler. A 14mg patch at 4pm resolved the issue and the patient was encouraged to use high-dose patches until he could comfortably abstain, and then reduce the morning dose.

“For smokers with coronary heart disease, stopping smoking decreases all cause mortal-ity by 36 percent,” he concluded.


Omega-3 fatty acids may reduce CV risk in smokers Elvira Manzano

Omega-3 polyunsaturated fatty acids (PUFA) perform better than placebo in

reversing the endothelial damage caused by smoking, according to a small study conduct-ed in Greece.

Adult smokers treated with 2 grams of omega-3 fatty acids daily for 12 weeks had significant improvements in endothelial func-tion and arterial stiffness, with a parallel an-ti-inflammatory effect. This was matched by improvements in flow mediated dilatation (FMD; P<0.05), augmentation index (ALX; P<0.001) and carotid-femoral pulse wave ve-locity (PWV; P<0.01) values. [Int J Cardiol 2011 Epub ahead of print]

“These suggest that omega-3 fatty acids in-hibit the detrimental effects of smoking on ar-terial function, which is an independent prog-nostic marker of cardiovascular risk,” said lead study author Dr. Gerasimos Siasos, from the University of Athens Medical School, 1st Department of Cardiology, Hippokration Hospital in Greece. He said the cardioprotec-tive effects of omega-3 fatty acids may be due to “a synergism between multiple, intricate mechanisms involving anti-inflammatory and anti-atherosclerotic effects.”

Siasos and his fellow researchers evaluated the effects of short-term treatment with omega-3 PUFAs in 20 healthy smokers at baseline, day 28 and day 84. At the end of the study period, ome-ga-3 PUFAs decreased endothelial dysfunction


and improved arterial elastic-ity or distensi-bility in this co-hort of patients.

Endothelial dysfunction is an early marker for atherosclerosis and can be detected before structural changes to the vessel wall become apparent (on angiography or ultrasound). Reduced arterial distensibility contributes to a disproportionate increase in systolic pres-sure and arterial pulsatility and is associated with cardiovascular morbidity and mortality.

Commenting on the study, Dr. Kathryn Taubert, chief science officer of the World Heart Federation, said the only way to pro-tect the body from the harmful effects of to-bacco is to stop smoking. “We encourage all people, both smokers and non-smokers, to eat healthy diets which include foods rich in omega-3 fatty acids.”

The American Heart Association (AHA) recommends consumption of at least two servings of fish, especially those rich in ome-ga-3 fatty acids such as salmon, sardines, herring, tuna and halibut, per week. Other good sources of omega-3 fatty acids are dark green leafy vegetables and nut oils, though the body cannot process these as easily as the docosahexaenoic acid (DHA) and eicosapen-taenoic acid (EPA) omega-3 fatty acids found in fish.

Omega-3 fatty acids improve arterial elasticity in healthy smokers.


Daily exercise may help hypertensive patients live longerElvira Manzano

Even low levels of daily physical activity could reduce the risk of death in individ-

uals with high blood pressure, according to a new study.

In a cohort of 416,175 adult individuals in Taiwan, those who exercised an average of 15 minutes a day or 90 minutes a week were found to have a 14 percent lower risk of dy-ing from cardiovascular disease (CVD) and all causes compared with those who did not exercise. Life expectancy was also longer by 3 years in the physically active group. Every additional 15 minutes of exercise (beyond the minimum 15-minute duration) further re-duced all-cause mortality by 4 percent (95% CI 2.5-7). [Lancet 2011;378:1244-1253]

These benefits applied to all age groups and both sexes, including those with CVD risks, said study author Dr. Chi-Pang Wen, from the Institute of Population Health Sci-ences, National Health Research Institute in Zhunan, Taiwan.“The reduction in mortality risk was equivalent to a permanent reduc-tion of 50 mmHg in blood pressure, over and above any anti-hypertensive medications.”

In their prospective cohort study, Wen and colleagues compared the all-cause and CVD mortality risks of men and women participat-ing in standard medical screening programs in Taiwan from 1996 to 2008. They found that inactive individuals had a 17 percent greater risk of mortality (HR 1.17, 95% CI 1.10-1.24) than active individuals.


The study was the first to quantify the impact of exercise on the risk pro-file of people with high blood pres-sure. “Appre-ciating this relationship will hopefully help to motivate inactive hypertensive patients to exercise,” said Wen.

At least 31 percent of the world’s popula-tion does not get sufficient exercise. Two out of five adults have hypertension. Clinicians would normally concentrate on treating hy-pertension as patients do not see the relevance of physical activity with blood pressure.

“Medications can lower blood pressure, but are temporary, costly and have side effects. Exercise is cost-free and with perma-nent [beneficial] effect,” Wen said. “Doctors should also discuss the importance of physi-cal exercise as a means to manage the CVD and all-cause mortality risks,” he concluded.

Studies have shown that a sedentary lifestyle is one of the major risk factors for CVD, the others being uncontrolled hypertension, hypercholesterolemia, obe-sity and smoking. Modifying these risk fac-tors through regular exercise, healthy eat-ing and smoking cessation can reduce the risks of a future heart attack, stroke or premature death.

Exercise has permanent beneficial effects on CVD.

SAVE THE DATE

SINGAPORE17 – 19 SEPTEMBER 2012WWW.HIMSSASIAPAC.ORG/12

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ACE inhibitors versus ARBs: Myths and Facts

Professor Frank RuschitzkaHeart Failure/Transplantation Clinic University Clinic Zurich Switzerland

The pathophysiology of hypertension involves several factors and its management necessitates an individu-alised approach; with treatments tailored to an indi-vidual’s patient profile. International consensus guide-lines recommend the stratification of cardiovascular risk of individual patients to quantify prognosis as well as to determine an optimal treatment approach based on individual risk profile. For example a patient with Grade 1 hypertension (SBP: 140-159; DBP: 90-99) with no other additional risk factors would be advised to make lifestyle changes for several months before a drug treatment was initiated. However, a patient having similar Grade 1 hypertension with concurrent presence of three or more risk factors or diabetes would require immediate drug treatment and inten-sive lifestyle changes.

“ The evidence underscores that hypertension cannot be treated in isolation as just blood pressure. It is part of the whole cardiovascular continuum and the ultimate treatment goal should be to reduce overall morbidity and mortality ”

Role of RAAS targeted therapy in the management of hypertension

Angiotensin II plays a central role in organ damage; treatment of hypertension should thus focus on reducing angiotensin levels. ACE inhibitors and angiotensin receptor blockers (ARB) are the two main drug classes that act on the RAAS. However, while ACE inhibitors reduce angiotensin II levels and increase bradykinin; ARBs have an antagonist action only on AT1 receptors, one of the four types of angiotensin receptors present.

“ Moreover, receptor blockade by an ARB conversely triggers substantial increase in angiotensin II levels ”

The benefits of ACE inhibitor therapy in reducing car-diovascular risks was demonstrated in the EUROPA, wherein 12,218 patients with stable coronary artery disease and no apparent heart failure were randomized to receive an ACE inhibitor “perindopril” or a matching placebo. After a mean follow-up period of 4.2 years, treatment with perindopril was found to confer a 20% relative risk reduction in cardiovascular death, myocar-dial infarction, or cardiac arrest.1 This has been further corroborated in a meta-analysis of ACE inhibitor trials in coronary artery disease patients without heart failure

or left ventricular dysfunction, which reported a signifi-cant reduction of 14% in all cause mortality, 19% in cardiovascular mortality, 18% in myocardial infarction, and a 23% reduction in stroke.2 In addition, there was a 42% reduction in cardiac arrest, an 8% reduction in myocardial revascularization and a 24% reduction in hospitalization for heart failure with ACE inhibitor based treatment.2

Preferred combination approach to hypertension management

Since several mechanisms are involved in the patho-genesis of hypertension; most patients require com-bination therapy to ensure optimal blood pressure control. Due to their complementary modes of action, ACE-inhibitors and calcium antagonists are the combi-nation therapy of first choice.3 This was demonstrated in the ASCOT-BPLA, a multicentre randomized con-trolled trial in 19,257 patients with hypertension and at least three other cardiovascular risk factors who were randomised to amlodipine plus perindopril or atenolol and bendroflumethiazide based therapy. Following 5.5 years follow up, patients on the perindopril and am-lodipine combination reported significantly fewer fatal and non-fatal stroke (P=0.0003), total cardiovascular events and procedures (P<0.0001), and all-cause mortality (P=0.025) as compared to those patients on atenolol and thiazide diuretic based regimen. Patients on perindopril plus amlodipine were also less likely to develop new onset diabetes, renal impairment and car-diovascular events and procedures [Figure 1].4

The combination of perindopril and thiazide like diu-retic indapamide has also demonstrated meaningful

reduction in recurrent stroke in the PROGRESS tri-al over four years [Figure 2].5 The combination has also been associated with significant reduction in all cause mortality in type 2 diabetes patients in the ADVANCE randomised controlled trial.

The Class Effect Myth: Are ACE inhibitors and sartans created equal?

In contrast, in the TRANSCEND trial, ARB telmisar-tan based therapy failed to prevent cardiovascular death, myocardial infarction, stroke, or heart failure hospitalisation in ACE inhibitor intolerant subjects with cardiovascular disease when compared to pla-cebo.7 Further in the PRoFESS study, telmisartan compared to placebo did not significantly lower the rate of recurrent stroke. Similarly, in the NAVIGATOR trial, valsartan therapy over 5 years did not reduce the rate of cardiovascular events for patients with im-paired glucose tolerance and established cardiovas-cular disease or risk factors.9 Of particular concern is the increased risk of myocardial infarction and a trend towards increased risk of stroke reported with valsar-tan as compared to amlodipine based therapy in the VALUE study on hypertensive patients with high car-diovascular risk.10 More recently in the ACTIVE I tri-als, the study investigators concluded that irbesartan did not reduce cardiovascular events in patients with atrial fibrillation.11

Cough is one of the troublesome side-effects of ACE inhibitor therapy; however this often resolves over time, and the rate of treatment discontinuation due to cough remains low. In contrast side-effects such as hypotension and renal causes, which are more frequently associated with ARB therapy than ACE inhibitors, results in permanent treatment discontinuation in greater proportion of patients, as reported in the VALIANT study.12

ConclusionAn overview of the current evidence base confirms that ACE inhibitors, especially perindopril, are the treat-ment of choice for hypertension. When a combination of agents is required for optimal cardiovascular risk re-duction, concurrent therapy of perindopril with calcium channel antagonist (such as amlodipine) and a statin may be considered ideal.

References

1. Fox KM, et al. Lancet. 2003 Sep 6;362(9386):782-8. 2. Danchin N et al. Arch Int Med. 2006;166:787-796. 3. 2007 ESH-ESC Guidelines for the man-agement of arterial hypertension: the task force for the management of arte-rial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Blood Press. 2007;16(3):135-232. 4. Dahlöf B, et al. Lancet. 2005 Sep 10-16;366(9489):895-906. 5. PROGRESS Collaborative Group. Lancet. 2001 Sep 29;358(9287):1033-41. 6. Patel A; et al. Lancet. 2007 Sep 8;370(9590):829-40. 7. Yusuf S, et al. Lancet. 2008 Sep 27;372(9644):1174-83. 8. Yusuf S, et al. N Engl J Med. 2008 Sep 18;359(12):1225-37. 9. McMurray JJ et al. N Engl J Med. 2010 Apr 22;362(16):1477-90. 10. Julius S, et al. Lancet. 2004 Jun 19;363(9426):2022-31. 11. Connolly SJ. N Engl J Med. 2011 Mar 10;364(10):928-38. 12. Pfeffer MA, et al. N Engl J Med. 2003 Nov 13;349(20):1893-906.

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EUROPA = European Trial on Reduction of cardiac events with Perindopril in stable coronary artery disease. ASCOT-BPLA = Anglo Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm. PROGRESS = Perindopril pROtection aGainst REcurrent Stroke. ADVANCE = Action in Diabetes and Vascular Disease: PreterAx and DiamicroN MR Controlled Evaluation. TRANSCEND = Telmisartan Randomized AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease. PRoFESS = Prevention Regimen for Effectively Avoiding Second Strokes. NAVIGATOR = Nateglinide and Valsartan Impaired Glucose Tolerance Outcomes Research. VALUE = Valsartan Antihypertensive Long-term Use Evaluation. ACTIVE I = Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events. VALIANT = VALsartan In Acute myocardial iNfarcTion.

The renin-angiotensin-aldosterone system (RAAS) plays a key role in regulating blood pressure and its inhibition is one of the important anti-hypertensive strategies. At a recent symposium in Singapore, renowned cardiologist Professor Frank Ruschitzka, presented clinical evidence from large scale randomised clinical trials establishing angiotensin-converting-enzyme (ACE) inhibitors to be the number one choice for hypertension and cardio-protection.

ACE inhibitors- The treatment of choice to reduce overall

cardiovascular risk in hypertension management

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events and procedures

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-15%

The ASCOT patient:Hypertention with 3 or more CV risk factors P. Sever, Lancet 2005

Figure 1: Benefits of Perindopril/Amlodipine over Atenolol/Diuretic (ASCOT) in hypertensive patients at risk (N = 19,257)4

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Figure 2: Perindopril/Indapamide Prevents Stroke (PROGRESS) in post stroke patients (N=6105)

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Figure 3: Perindopril/Indapamide reduces All-cause Mortality in type 2 Diabetes (ADVANCE); (N=11,140)6

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40 June 2012 Diabetes

Doctors have exaggerated fears when starting patients on insulin

Elvira Manzano

Physicians may be more concerned about side effects and slower to start insulin

therapy than patients themselves, according to a meta-analysis.

In a review of randomized controlled tri-als involving insulin-naïve patients, the bar-riers to insulin initiation perceived by phy-sicians, for example, fear of hypoglycemia and weight gain, were amplified compared with patient perception. Doctors were also more concerned about injection-related pain and anxiety than their patients. [CMAJ 2012. DOI:10.1503/cmaj.110779]

“Insulin is effective in lowering blood sug-ar,” said lead study author Dr. Catherine Yu, a researcher at the Keenan Research Center, St. Michael’s Hospital in Toronto, Canada. “But there are no clear recommendations on the saf-est and most effective way to start patients on it, so physicians are often hesitant to do so.”

Yu and colleagues analyzed past studies examining the effects of insulin on glycemic control, weight gain, risk of hypoglycemia and other adverse effects in outpatients with type 2 diabetes and found that insulin is safe and effective in reducing glycosylated he-moglobin (HbA1c). Insulin use is associated with weight gain, but not with an increased risk of hypoglycemia.

“When some physicians think of the side effects of insulin and the barriers to starting it, they’re often thinking about the older types [of insulin] and older delivery systems,” Yu

said. “So a lot of the hesitation may be that their way of thinking about the drug has not changed along with the new types of insulin that are used.”

She added that new insulin is better and used in smarter ways, thus there is less risk of hypoglycemia and weight gain. “Everyone knows that insulin works, but the key point here is that it’s safe and can be straightfor-ward to use, too.”

The researchers used their findings to de-velop recommendations for physicians and healthcare providers on how to start patients on insulin.

41 June 2012 Diabetes

“Insulin initiation should be considered early in the course of type 2 diabetes. A basal regimen is an ideal one to start with given its simplicity and favorable safety profile,” the authors advised.

In the meta-analysis, patients treated with pre-mixed and basal-bolus regimens had greater HbA1c reduction compared with pa-tients who received basal insulin. However, both regimens were associated with more weight gain, and in the case of pre-mixed reg-imen, an increased risk of hypoglycemia.

Current guidelines vary as to the recom-mended criteria for the initiation of insulin

in patients with type 2 diabetes. Canadian guidelines recommend insulin as a first-line therapy in patients with HbA1c value of 9.0 percent or greater in those with newly-diag-nosed diabetes. US and European guidelines recommend basal insulin as a second-line agent if the HbA1c value is >7.0 percent after metformin monotherapy.

For patients taking antihyperglycemic agents, the authors recommend continuation of medi-cations with insulin. “The combination therapy reduces weight gain, insulin dose and risk of hypoglycemia compared with insulin therapy alone,” the authors concluded.

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42 June 2012 In Pract ice

Low back pain: Current concepts

Low back pain (LBP) is a common and chal-lenging health problem in primary care. There is a point prevalence of 15 to 30 percent and a lifetime prevalence of between 50 and 85 per-cent. [Spine (Phila Pa 1976) 2001;26(22):2504-13; discussion 2513-4]

Nonspecific low back pain (NSLBP) com-prises approximately 85 percent of all back pain diagnoses and affects 80 percent of adults. It is associated with enormous ex-pense in terms of healthcare expenditures, and work- and disability-related losses. Mean direct and indirect costs for LBP care are twice as high for patients with chronic LBP when compared with acute LBP. The severity of LBP (high disability and moderate-to-severe limi-tations in daily living) and depression are the two most important predictors of costs.

Currently, there is a shift in the clinical model of LBP from a biomedical ‘injury’ to a multifactorial biopsychosocial pain syndrome which erupts periodically over the course of a lifetime of an individual.

The consensus of clinical guidelines sug-gests that acute NSLBP patients should be re-assured of a good prognosis, educated in self-care, remain active and use over-the-counter medications as a first line of symptom control.

Many patients with low back pain have at least one red-flag sign. Red-flag signs have a

Dr. Eugene Wong Consultant Spine & Orthopedic SurgeonKuala Lumpur

poor test specificity. Thus, the evaluation of LBP should take into account the whole clini-cal presentation of the patient. The key is to have a high index of suspicion in high-risk patients or when more than one red flag is present. (Table 1)

Diagnostic and therapeutic management of LBP vary tremendously among GPs. A recom-mended approach to diagnosis and treatment is provided in Tables 2 and 3. An ideal ap-proach in managing LBP patients should be multidisciplinary and inter-professional. GPs could focus on pain management through medication, red-flag screening, encourage-ment to stay active and reassurance. Physi-cal therapy could focus on pain management, general exercise and encouragement to stay active. Occupational therapy could focus on disability prognosis, yellow-flags manage-ment (Table 4) and return to activity param-eters.

Patients with yellow flag signs require cog-nitive behavioral therapy, the aim of which is to change patients’ thoughts and beliefs about their pain. Adequate information and good communication between the primary care physician and patient is a prerequisite for a successful psychosocial intervention, but this will not guarantee a change in the way pa-tients behave and how they deal with their pain problem. The key to treatment success is that patients become active processors of in-formation, and not passive reactors. Patients should be active collaborators when changing misconceived thoughts and behaviors (Table 5). [Spine (Phila Pa 1976) 2008;33(1):81-9]

43 June 2012 In Pract iceA high proportion of patients recover from

acute back pain. Reductions in pain and dis-ability have to be more than 50 percent to be consistent with recovery from LBP. [Spine (Ph-ila Pa 1976) 2011;36(26):2316-23]

When should LBP cases be referred to a spine surgeon? Indications would include patients with no response after 6 weeks of conservative treatment, patients with radicu-lar syndrome, presence of nerve root tension signs, suspicion of a pathologic change, cauda equina syndrome and MRI showing disc pro-trusion or prolapse.

To rationalize the approach of LBP and to take account of emerging scientific evidence, clinical guidelines on the management of LBP have been issued in various countries. This

Cancer• Age >50 or <17.• History. • Unexplained weight loss of >10 kg

within 6 months.• Failure to improve with therapy.• Pain persists for more than 6 weeks.• Pain at rest or at night.

Infection • Severe pain. • Persistent fever. • History of intravenous drug abuse.• Recent bacterial infection.• Urinary tract infection or

pyelonephritis.• Pneumonia.• Wound (eg, decubitus ulcer) in spine

region.• Immunocompromised state.• Systemic corticosteroids.• Organ transplant.• Diabetes mellitus.• Human Immunodeficiency Virus

(HIV).• Pain at rest.

Cauda Equina Syndrome • Urinary incontinence or retention.• Saddle anesthesia.• Anal sphincter tone decreased or fecal

incontinence.• Bilateral lower extremity weakness or

numbness.

• Progressive neurologic deficit.• Major motor weakness.• Major sensory deficit.

Significant herniated nucleus pulposus• Major muscle weakness (strength 3

of 5 or less).• Foot drop.

Vertebral fracture • Prolonged use of corticosteroids.• Age greater than 70 years.• History of osteoporosis.• Mild trauma over age 50 (or with

osteoporosis).• Recent significant trauma at any age.

Abdominal Aortic Aneurysm • Abdominal pulsating mass.• Atherosclerotic vascular disease.• Pain at rest or nocturnal pain.

Gastrointestinal/ Genitourinary• Abdominal tenderness.• Rebound tenderness.• Diarrhea/constipation.• Anuria, oliguria, polyuria.• Abnormal menses, dyspareunia.

General (weak test specificity)• Vertebral tenderness.• Limited spine range of motion.

Table 1: Red flags

• History taking and physical examination to exclude red flags.• Diagnostic triage (nonspecific LBP, radicular syndrome, specific pathologic change).• Physical examination for neurologic screening.• Radiographs not useful for nonspecific LBP.• Consider psychosocial factors if there is no improvement.

Table 2: Recommendations for diagnosis of LBP • Combat demoralization by assisting patients to change their view of their pain from overwhelming to manageable.

• Assist patients to reconceptualize themselves as active, resourceful and competent.• Help patients in coping strategies and techniques to help them adapt and respond to

pain and the resultant problems.• Teach patients how to anticipate problems proactively and generate solutions.• Attribute successful outcomes to their own efforts.

Table 5: Aims of a cognitive behavioral approach

Acute or Subacute Pain• Reassure patients (favorable prognosis).• Advise to stay active.• Prescribe medication if necessary – paracetamol, nonsteroidal anti-inflammatory

agents, muscle relaxants or opioids.• Discourage bed rest.• Do not advise back-specific exercises.

Chronic Pain• Refer for exercise therapy.

Table 3: Recommendations for treatment of LBP

Psychiatric disorders • Anxious, depressed, social withdrawal.• Misconception of danger of back disorders.• Somatization; poor sleep because of back pain.

Socioeconomic issues• Occupation related (heavy lifting, unsociable working hours, high mental workload,

prolonged time off work, dissatisfaction with work, lack of work support, problems with claims or compensation, and no economic gain from resuming work).

• Economic/ social hardships (eg, death in the family, divorce or loss of income).

Behavior • Inappropriate or limited belief of improvement or ability to work.• Expectation that passive treatment (physical agents, extended bed rest) is better than

active participation (exercise, walking, working). • High fear-avoidance behavior scale score.• High kinesiophobia scale score.

Miscellaneous• Confusion about diagnosis and prognosis.• Misunderstandings about the cause of pain.• Negative experience with previous intervention for back pain.

Table 4: Yellow Flags

brings us to the question: is there a need for such a guideline to address the issue of LBP in the local population?

LBP can be managed successfully in the primary care setting through a program of activity modification, reassurance, short-term symptom control and alteration of in-appropriate beliefs about the correlation between back pain and impairment. Mul-tiple evidence-based guidelines exist, but a fundamental concern is the current lack of knowledge on the best ways to change the behavior of clinicians.

44 June 2012 Calendar

June10th International Conference of the Asian Clinical Oncology Society13/6/2012 to 15/6/2012 Location: Seoul, Korea Tel: (82) 2 3476 7700Fax: (82) 2 3476 8800Email: [email protected] Website: www.acos2012.org

15th International Congress of Infectious Diseases13/6/2012 to 16/6/2012Location: Bangkok, ThailandTel: (617) 277 0551Fax: (617) 278 9113Email: [email protected] Website: www.isid.org/icid/

International Society for Stem Cell Research 13/6/2012 to 16/6/2012Location: Yokohama, Japan Tel: (847) 509 1944Fax: (847) 480 9282Email: [email protected] Website: www.isscr.org/annual_meeting_home.htm

World Conference on Interventional Oncology 14/6/2012 to 17/6/2012Location: Chicago, Illinois, US Tel: (1) 202 367 1164Fax: (1) 202 367 2164Email: [email protected] Website: www.wcio2012.org

67th Annual Meeting of the Canadian Urological Association 23/6/2012 to 27/6/2012Location: Banff, Alberta, Canada Info: Canadian Urological Association Tel: (1) 450 550 3488Fax: (1) 514 227 5083Email: [email protected] Website: www.cuameeting.org

15th World Congress of Pain Clinicians27/6/2012 to 30/6/2012Location: Granada, SpainInfo: Kenes InternationalTel: (41) 22 908 0488Fax: (41) 22 9069140Email: [email protected] Website: www.kenes.com/wspc

ESMO 14th World Congress on Gastrointestinal Cancer27/6/2012 to 30/6/2012Location: Barcelona, SpainInfo: European Society of Medical Oncology Tel: (770) 751 7332Fax: (770) 751 7334Email: [email protected]: www.worldgicancer.com

July30th International Congress of Psychology 22/7/2012 to 27/7/2012Location: Cape Town, South Africa Tel: (27) 11 486 3322 Fax : (27) 11 486 3266E-Mail: [email protected] Website: www.icp2012.com

17th World Congress on Heart Disease 201227/7/2012 to 30/7/2012Location: Toronto, Ontario, CanadaInfo: International Academy of CardiologyTel: (1) 310 657 8777 Fax : (1) 310 659 4781 E-Mail: [email protected] Website: www.cardiologyonline.com

45 June 2012 CalendarUpcomingEuropean Society of Cardiology Congress 201225/8/2012 to 29/8/2012Location: Munich, GermanyInfo: European Society of CardiologyTel: (33) 4 9294 7600 Fax: (33) 4 9294 7601 E-Mail: [email protected] Website: www.escardio.org/congresses/esc-2012

15th Biennial Meeting of the European Society for Immunodeficiencies (ESID 2012)3/10/2012 to 6/10/2012Location: Florence, ItalyTel: (41) 22 908 0488Fax: (41) 22 732 2850Email: [email protected]: www.kenes.com/esid

42nd Annual Meeting of the International Continence Society 15/10/2012 to 19/10/2012Location: Beijing, ChinaTel: (41) 22 908 0488Fax: (41) 22 906 9140Email: [email protected]: www.kenes.com/ics

National Diagnostic Imaging Symposium 2/12/2012 to 6/12/2012Location: Orlando, Florida, USInfo: World Class CME Tel: (1) 980 819 5095Email: [email protected]: www.cvent.com/events/national-diag-nostic-imaging-symposium-2012/event-summary-d9ca77152935404ebf0404a0898e13e9.aspx

Asian Pacific Digestive Week 20125/12/2012 to 8/12/2012Location: Bangkok, ThailandTel: (66) 2 748 7881 ext. 111Fax: (66) 2 748 7880E-mail: [email protected]: www.apdw2012.org

World Allergy Organization International Scientific Conference (WISC 2012)6/12/2012 to 9/12/2012Location: Hyderabad, IndiaInfo: World Allergy OrganizationTel: (1) 414 276 1791Fax: (1) 414 276 3349E-mail: [email protected]: www.worldallergy.org

46 June 2012 After Hours

One doctor tells of his evolving culinary creations at home in

addition to crafting healthy traditional meals for the whole

family. Rajesh Kumar reports.

Dr. Poh Beow Kiong is a d i e h a r d

foodie. His day job as a urology consultant at Singapore’s Changi General Hospital keeps him quite busy. But on occasional weekday evenings and the weekends, Poh takes on the role of a kitchen maestro, whipping up quick, healthy dinners for the family.

“Some fi nd cooking to be a chore,” he says, “But I fi nd it therapeutic. It relaxes me after a long day at work.”

Besides, the family doesn’t like to eat out. “Occasionally, when we do, it is on days when our kids go for swimming lessons. We buy takeouts rarely,” said Poh.

While he has not developed a signature style, Poh said his cooking has undergone a sort of evolution over the years.

“Ten years ago, we used to eat a lot of fried food and used more oil in our cooking. Now, we are more health conscious and tend to steam our fi sh, vegetables and even chicken, rather than fry them.”

While healthy eating is the norm, Poh occasionally indulges in fatty food and believes cer-tain traditional recipes shouldn’t be altered, no matter how calorie dense the dish may be.

47 June 2012 After Hours

“Chinese fatty pork cooked in duck soya sauce, for example. That is an extremely greasy but sumptuous dish. And trying to cook it with anything other than fatty pork is pointless,” he said.

“Obviously, you don’t eat such food regu-larly and need to burn off the extra calories through vigorous exercise. Else, the coro-nary arteries will clog up,” cautioned Poh.

“But many special dishes, and the way they are cooked, are a part of our cultural heritage that needs preserving …You ask your mum how these are cooked, write down the recipes, add your tweaks over the years and pass them on to the next genera-tion. That should never be lost!”

Is there a favorite dish he likes more over others? “My mother’s home cooked popiah is the best,” Poh said excitedly. Like chilly crab, popiah is among Singapore’s iconic dishes and that is prepared by wrapping a choice of cooked fillings in paper thin crepe, usually bought ready made from the market.

Dried shrimps and cooked pork, vegeta-bles, mushrooms, crab meat and other in-gredients can be mixed with boiled radish to make different fillings. The crepe is used as it

is and rolled up like a sushi roll after dabbing it with sweet sauce, hot chilli paste and stuffing the fillings before cutting the rolls into pieces.

Poh’s culinary skills have endeared him to his family and the mother-in-law. He en-courages his fellow physicians to try their hand at cooking and offers to share the rec-ipe for a healthy snack, which anyone with negligible cooking skills can master:

Take a chunk of egg tofu. Pan fry it, drain the excess oil on kitchen paper and cut into pieces. Chop and fry some garlic to pleasant golden brown color, sprinkle on tofu pieces and, voila!

The natural sweetness of the egg tofu and light pungency of the fried garlic work so well together that you may not need a dipping sauce. Just make sure not to over-cook the garlic, or it will taste bitter.

The cooking process continues even after you turn off the heat. As the garlic turns light brown, turn the heat off and drain out the excess oil before it overcooks. It’s not easy to brown the egg tofu. Pat it dry with kitchen paper, drizzle oil on a really hot pan and leave it to sizzle on one side for several minutes before turning it over.

Photo credits: Changi General Hospital

48 June 2012 Humor

“You're a very lucky man Harry, you could have broken your nose!”

“I have good news and bad news. The bad news is that the DNA tests showed that it was your blood they found at the crime scene.

The good news is your cholesterol is down to 120!”

“I've terrible news. You are not a hypochondriac!”

“I'm sick of being sick Doctor. Is there an illness other than the one I have that I might

enjoy?”

“The place is empty. Everybody called in sick!”

“Enjoy your vacation. I'll tell you the bad news

when you get back!”

“I thought you told me to go on a diet just to be mean!”

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