philippines march new dengue vaccine deemed effective and...
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PHILIPPINES MARCH 2015
New dengue vaccine deemed effective and safe
FEATURELudan’s method and Dr Ludan’s other legacies to pediatrics
FORUMIncineration: Impact on health and climate
MARKET WATCHThe Medical City offers transradial catheterization
NEWSTraining course effective in preparing to respond to Ebola
20-22 August 2015 • Singapore • Raffles City Convention Centre
The Synthesis of Evidence, Experience, and Choice in Women’s Health Call for Abstracts, Registration,and Programme atwww.sicog2015.com
DR CAROL TAN
A novel vaccine against dengue has been
found to be effective and safe, based on
a randomized controlled trial conducted by Dr
Maria Rosario Capedeng, et al.
The study was a phase three multi-centered
trial held in five Asia-Pacific countries. Healthy
children aged two to fourteen years were ran-
domly assigned to receive three injections of
either recombinant live attenuated, tetravalent
dengue vaccine (CYD-TDV) or placebo, given
six months apart (months 0, 6, and 12) at three
centers in Indonesia, two centers in Malaysia,
two centers in the Philippines, three centers in
Thailand, and two centers in Vietnam. A total of
10,275 children were included in the study, with
6,851 children receiving the dengue vaccine
and 3,424 children receiving placebo. The par-
ticipants were then followed up for 25 months
to determine whether they developed dengue
infection or any serious adverse events. The
primary endpoint of the study was for the lower
bound of the 95 percent confidence interval of
vaccine efficacy to be greater than 25 percent.
[Lancet 2014;384;9951:1358-65.]
Outstanding resultsResults of the study showed that a total of
250 cases of virologically confirmed dengue
were recorded more than 28 days after the third
injection. Out of the 250 cases, 47 percent or
117 cases occurred in the vaccine group, while
53 percent or 133 cases occurred in the control
group. The vaccine efficacy was computed at
56.5 percent with a 95 percent confidence in-
terval of 43.8 to 66.4 percent; thus, the study’s
primary endpoint was met.
Furthermore, the authors reported that the
dengue infections were found to be milder in the
vaccine group than in the control group. Only
40 participants (less than 1 percent) from the
vaccine group necessitated hospital admission
due to virologically confirmed dengue infection,
compared to 61 participants (two percent) from
the control group. The vaccine efficacy against
hospitalized dengue was computed at 67.2 per-
cent, with a 95 percent confidence interval of
50.3 to 78.6 percent.
There were a total of 647 serious adverse
events recorded in the study, of which 402
events occurred in the vaccine group and 245
events occurred in the control group. Only 54
participants (one percent) in the vaccine group
and 33 participants (one percent) in the control
group had serious adverse events occurring
MARCH 2015 3
New dengue vaccine deemed effective and safe
within 28 days of the vaccination. These adverse
events were mainly infections and injuries that
were consistent with common medical disorders
observed in the age group of the participants.
The authors concluded the dengue vaccine
is effective when given as a three-dose series to
children living in endemic areas, and has a good
safety profile. Although the vaccine only has a
moderate over-all efficacy, it can still have a sub-
stantial public health benefit especially consid-
ering the high disease burden of dengue in Asia.
Award-winning publicationThis publication was awarded Paper of the
Year 2014 by the International Society of Vac-
cines. The principal investigator of the study
is Dr. Capedeng, who is head of the Research
Institute of Tropical Medicine of the Philippine’s
Department of Health. She was also included in
the 2014’s list of Top Women in Biotech Industry.
Controversies on ‘breakthrough’ dengue drug
Meanwhile, another experimental approach
to dengue was axed. The Department of Health
(DOH), led by acting health secretary Janette
Garin has suspended a local clinical trial of the
controversial ActRx TriAct. The ActRx TriAct is
a combination of the compounds artemether,
artesunate, and an herbal compound called ber-
berine. This drug was said to be a breakthrough
drug for dengue, and was approved to be dis-
tributed to six government hospitals as part of a
clinical trial.
Garin stated that this drug cannot be used
in clinical trials since it has not yet been reg-
istered with the Food and Drug Administra-
tion (FDA Philippines). According to DOH,
the trial did not comply with the International
Conference on Harmonization Guidelines for
Good Clinical Practice. This finding was sup-
ported by the Philippine Council for Health
Research and Development, which stated that
the study lacks scientific justification for the
use of artemether and artesunate for dengue
treatment.
According to DOH, the researchers behind
this clinical trial must be held accountable.
Aside from endangering the lives of the partici-
pants included in the study, the ActRx TriAct also
has a potentially disastrous public health effect.
Artemether and artesunate are both made from
artemesin, which is a drug used for malaria. To
prevent drug resistance, artemesin is adminis-
tered with other drugs such as lumifrantrine and
primaquine in the treatment regimen for malaria.
In the ActRx TriAct, artemether and artesunate
are used as monotherapy, which may increase
the development of resistance to this important
anti-malarial drug.
Dr. Francisco Tranquilino, regent of the Phil-
ippine College of Physicians Board, agreed
that the clinical trial is technically and ethically
flawed, and should not have been initiated at
all. Dr. Maria Minerva Calimag, president of the
Philippine Medical Association, shares the same
sentiment. She explained that a drug that is ef-
fective for malaria cannot be presumed to be ef-
fective for dengue, since malaria is caused by
a protozoa while dengue is caused by a virus.
The WHO representative to the Philippines, Dr.
Julie Hall, emphasized that artemisin is a pre-
MARCH 2015 4
cious public health drug and should be used ju-
diciously to prevent drug resistance.
Other updates in dengue managementDue to the changes in the epidemiology of
dengue over the past years, a new classification
was created by the World Health Organization
(WHO) last 2012. Patients are now classified as
having dengue without warning signs, dengue
with warning signs, or severe dengue.
Patients are labeled as dengue without warn-
ing signs if they live in or travel to dengue-en-
demic areas, and experience fever with any two
of the following symptoms—headache, body
malaise, myalgia, arthralgia, retro-orbital pain,
anorexia, nausea, vomiting, diarrhea, flushed
skin, and rash. These patients must also have
leucopenia with or without thrombocytopenia
on complete blood count, or a positive dengue
NS1 antigen or IgM antibody test.
The criteria for dengue with warning signs
consist of patients who live in or travel to den-
gue-endemic areas, with fever lasting for two to
seven days. They must also exhibit at least one
of the warning signs, such as abdominal pain or
tenderness, persistent vomiting, clinical signs of
fluid accumulation, mucosal bleeding, lethargy,
restlessness, liver enlargement, an increasing
hematocrit, or a decreasing platelet count.
Patients are classified as severe dengue
when they fulfill the criteria for dengue with or
without warning signs, plus any one of the follow-
ing—severe plasma leakage leading to shock or
fluid accumulation causing respiratory distress,
severe bleeding, or severe organ impairment.
Specifically, the WHO quantified organ impair-
ment as an AST or ALT level of at least 1000 for
the liver, the presence of seizures or impaired
consciousness for the brain, myocarditis for the
heart, and renal failure for the kidneys.
Aside from the proper classification and
management of dengue, the WHO continues
to emphasize that environmental manage-
ment is an important tool to control the burden
of disease. Several environmental strategies
are espoused by the WHO to minimize vec-
tor propagation. The supply of water and wa-
ter storage systems must be improved so that
water-storage containers that serve as larval
habitats are no longer necessary. Water-storage
containers must also be fitted with tight lids to
keep the mosquitoes out. Proper solid waste
management must also be practiced to reduce
larval habitats. Guidelines for the safe use of
insecticides are also enumerated in the WHO
dengue guidelines.
MARCH 2015 5
MARCH 2015 6
DR MEL M BELUAN
T he Department of Health (DOH) has report-
ed last March 11 at least one person in the
country tested positive for the Middle East Re-
spiratory Syndrome-Coronavirus (MERS-CoV).
The patient is a 32-year-old female nurse who
underwent testing when she exhibited flu-like
symptoms upon arrival in Manila from Saudi
Arabia last March 1, 2015.
DOH secretary Dr Janette Garin confirmed on
March 12 that the patient is 4 to 5 weeks pregnant,
making her situation precarious as pregnancy ren-
ders the immune system weaker. She stressed that
while her baby would likely not get infected, the
baby’s health depends on her condition.
As of March 12, the patient no longer had
fever and was in stable condition while being
observed in a negative-pressure room at the De-
partment of Health’s Research Institute for Tropi-
cal Medicine (RITM) in Muntinlupa City. Her hus-
band who arrived with her from the same flight is
also being monitored for symptoms in the same
room. It has to be recalled that a Filipino nurse,
who was tested in Saudi Arabia, entered the
country in September of last year. The nurse’s
test later came out positive.
The DOH has already traced 92 of the 225
other Saudi Airline flight 860 passengers, who
agreed to be tested. It is also observing other 56
individuals whom the nurse had close contact
with. Ten of them had contact with her when she
was admitted earlier in a hospital. The nose and
throat swab samples of the 56 contacts were
negative for the virus in the first round of tests.
However, 11 symptomatic contacts were admit-
ted at the RITM and would have another round
of tests using sputum and rectal swab samples.
Experts said that the risk of infecting other
passengers is low as the patient did not show
any symptoms while aboard the flight. MERS-
CoV has a mortality of 30 percent but human-
to-human transmission is difficult. As DOH de-
clared preparedness to handle the disease, it
also advised the public to be aware of its flu-like
symptoms such as fever, body pain and difficul-
ty of breathing. The agency asked uncontacted
passengers to communicate with them through
the numbers (02) 711-1001 or (02) 711-1002 if
they are having flu-like symptoms.
The emergency committee (EC) of the WHO
no longer considers MERS-CoV a Public Health
Emergency of International Concern (PHEIC). As
of MARCH 5, it noted 971 laboratory-confirmed
cases , including at least 356 deaths. MERS-CoV
was first reported in Saudi Arabia in 2012.
DOH confirms MERS-CoV case in the country
MARCH 2015 FORUM 7
Incineration: Public health impact, climate change implications and the Ebola epidemicDR MARY LAUREN EUROPA
Last January 28, the non-governmental or-
ganization Health Care Without Harm held
the forum “Incineration: Public Health Impact,
Climate Change Implications, and the Ebola Cri-
sis“ in Quezon City. The main speaker was Dr
Jorge Emmanuel, a renowned environmental-
ist and chief technical adviser on Health Care
Waste for the United Nations.
Emmanuel began by defining the precaution-
ary principle to unite the topics on incineration,
public health, climate change and the Ebola
crisis. This principle is the responsibility of ev-
ery decision-maker regarding evidence about
harmful effects of certain on human health and
the environment “[This] principle requires that
one should make a decision on the side of pre-
caution, and on the side protecting public health
and the environment,” he says.
Medical waste incineration (MWI) and dioxins
The main public health and environmental
implication of medical waste incineration is the
production of carcinogens called dioxins. In Eu-
rope, 62 percent of dioxin emissions are due to
technological processes, including MWI. In the
US, non-incineration methods resulted in a drop
of dioxin emissions from MWI, from 2470 g TEQ
(toxic equivalents) per year in 1987, to only 477
g TEQ/yr in 1995; despite that, MWI is still the
third largest source of dioxins. Moreover, “[i]
ncineration also releases other toxic pollutants,
like lead, cadmium, and mercury, acid gases,
carbon monoxide, particulate matter, incinerator
ash, and other organic compounds ,” adds Em-
manuel.
Dioxins and health effects“Dioxins” are a family of polychlorinated
dibenzo-p-dioxins and dibenzofurans, which are
extremely toxic . “Their effects are appreciated
at doses of parts per billion, or trillion,” says Em-
manuel, “like a drop of water in a medium sized-
lake.” Based on animal studies, the US Environ-
mental Protection Agency developed a cancer
potency factor in 2002, which pegged dioxin
at 0.000000000001 g TEQ/kg/day. In humans,
dioxins have been noted to produce develop-
mental malformations and birth defects, cogni-
tive retardation, and changes in sex ratio (fewer
male births). Dioxins also suppress the immune
system, decrease fertility and increase cases of
endometriosis in females, and decrease testos-
terone levels, sperm count, and penis and tes-
ticular size in males.
Dioxins are extremely persistent, with an
environmental half-life ranging from 9 to more
than 1000 years. Emmanuel stressed that this
makes the precautionary principle relevant,
because releasing dioxins today will affect not
only our lives, but the lives of future genera-
tions.
MARCH 2015 FORUM 8
Studies on the health effects of incinerationMany studies have been done on residents
living within a radius of about 10 km or less to
incinerators, and on the industrial workers at
these sites. These studies linked incineration
to cancers of the larynx, stomach, lung, colon,
rectum, and liver, and lung, with closer proxim-
ity to incinerators; high serum levels of lead,
cadmium and toluene, and urinary levels of tet-
rachlorophenols and arsenic; deaths from isch-
emic heart disease and lung cancer; and lethal
congenital anomalies and stillbirths near incin-
erators.(1-7)
Best available techniques The results of the studies led to the develop-
ment of regulations on dioxins. Emmanuel is a
member of the expert panel group that devel-
oped the guidelines for Best Available Tech-
niques (BAT) and Best Environmental Practices
under the Stockholm Convention, which seeks
to limit dioxin production and environmental
release. The limits may be achieved through
a suitable combination of primary and second-
ary measures, says Emmanuel. Primary mea-
sures would ensure the introduction of waste at
850°C or higher, as most dioxins are produced
during the transit periods of incinerators, when
the waste materials are introduced, and the tem-
peratures slightly dip down below 850°C.
Secondary measures are important, as it will
be unlikely to reduce dioxin production to ac-
ceptable levels with primary measures alone.
This would necessitate the use of technologies
that meet international standards, and would
include dedusting, with the fabric and ceramic
filters operating at optimum temperatures; the
use of cyclones for pre-cleaning; electrostatic
precipitators around 450°C; and the inclusion
of high performance adsorption units with acti-
vated carbon.
Non-incineration alternativesAn alternative to incineration is steam or auto-
clave-based systems. Autoclaves are markedly
cheaper to produce and maintain. According to
Emmanuel, due to political and business con-
siderations, more incinerators than autoclaves
are still being used, as they yield bigger profits.
There are advantages, however, in shifting to a
steam-based or autoclaving technology. This
would entail a shift from a “waste management”
to a “resource management” framework. Many
of the health care waste materials can now be
reusable and recycled after treatment.
An ideal medical waste management sys-
tem, however, is not dependent on technology,
but on a system that integrates waste classifica-
tion, segregation, minimization, systematic con-
tainerization, color coding, labeling, signage,
handling, transport, storage, treatment and final
disposal, and wastewater treatment and contin-
gency plans.
Successful health care waste management (HCWM) projects
An example of a successful HCWM project
spearheaded by Emmanuel was the India Proj-
ect (2010 – 2012) at the King George Medical
University Hospital. The hospital previously had
no proper HCWM, exemplified by poorly han-
dled infectious waste deposited at uncontrolled
dumpsites or burned in a makeshift incinerator.
Emmanuel’s team instituted storage and treat-
ment facilities with autoclaves and shredders,
color-coded segregation bins, informational
MARCH 2015 FORUM 9
posters and training, improved internal trans-
port system, waste tracking and CCTV systems.
These improvements led to the development
of an HCWM committee, a committed hospital
leadership and an infection control program.
Furthermore, recovery of recyclables provided
revenues which helped maintain the HCWM
system.
Emmanuel also participated in the Kyrgystan
Project (2005-2013). Kyrgystan, one of the poor-
est countries of the former Soviet Union, had
no national regulation on medical waste, and
little or no segregation of waste. After a national
assessment, Emmanuel’s team developed a
HCWM model which made use of reusable con-
tainers, waste minimization and recycling. By
the end of the program, all hospitals, primary
health centers and private clinics started to use
the model. Hospitals even reported a 33 percent
savings, and generated revenue from recycling.
Ebola crisisEmmanuel was also involved in the Ebola
Waste Project (2014). Incineration, which was
already problematic, was in place. In addition,
says Emmanuel, it poses hazards to workers, as
their personal protective equipment (PPE) have
combustible properties. This was addressed by
Emmanuel’s team via the establishment of au-
toclaves and HCWM guidelines. The autoclaves
were started to be built in Africa, instead of be-
ing imported, thereby reducing the overhead
costs. These systems made use of steam ejec-
tors instead of vacuum pumps, and mechanical
controls instead of computer controls, resulting
in fewer maintenance issues, and greater waste
volume reduction. These autoclaves could also
ride through power outages. According to Em-
manuel, these autoclaves exceeded interna-
tional standards, and are an excellent solution
to this Ebola crisis, for the following reasons: the
Ebola virus is destroyed by autoclaving within
seconds to minutes; the process does not re-
lease smoke, dioxins, hydrochloric acid, or other
toxic air pollutants; it is safe for workers wearing
PPE; special barrel trolleys protect workers from
Ebola exposure, and these are cheaper than in-
cinerators.
Climate change impact Emmanuel also talked about climate change
and global warming, to which emissions of in-
cinerators are contributory. “[There have been
marked increases in global carbon dioxide
(CO2) levels], with levels reaching 400 ppm for
the first time in human history in 2013,” he says.
Global climate change would impact heavily on
Southeast Asian countries like the Philippines.
Emmanuel states that Intergovernmental Panel
on Climate Change 4th Assessment and ADB
Reports mentioned potentially pervasive envi-
ronmental, health and socioeconomic effects.
Emmanuel ended his talk with a vision of an
alternative path in waste management: a para-
digm shift to recycling, conservation of earth’s
resources, and aiming for zero-waste and re-
newable clean energy.
References: 1. Occup Environ Med 1998;55:611-15. 2. Am J Ind Medi-cine 1997;31:659-61. 3. Environ Health Perspect 1996;104:750-54. 4. Br J Cancer 1996;73:702-10. 5. Int Arch Occup Environ Health 1995;68:13-21. 6. Am J Ind Medicine 1989;15:129-37. 7. J Epidemiol Commun H 2003;57:456-61.
MARCH 2015 NEWS 10
Training course effective in preparing Philippine hospitals to respond to Ebola virus diseaseDR JAMES SALISI
A three-day training course to prepare hospi-
tal staff for Ebola virus disease (EVD) was
“effective at increasing the level of knowledge
about EVD and the level of confidence in man-
aging EVD safely,” according to an article pub-
lished on the Western Pacific Surveillance and Response Journal. A total of 364 doctors, nurs-
es and medical technologists from 78 hospitals
across the Philippines were trained. Evaluation
of the workshop found significant increases in
knowledge about EVD (P<0.009) and confi-
dence in managing EVD (P = 0.018). [WPSAR 2015;6(1). doi:10.5365/wpsar.2014.5.4.008]
This comes as positive news in the midst of
heightened awareness and anxiety over the on-
going spread of EVD in Liberia and Sierra Leone
in Africa. Fear of this condition is borne out of
the high case fatality rates that could go up to 70
percent. The case fatality rates are 55 percent
for healthcare workers and 58 to 60 percent for
hospitalized patients according to the WHO.
Although the Western African EVD has not
reached the Philippines, the training was orga-
nized to increase the capacity to detect, isolate
and safely care for EVD cases in the country
should this come to pass. The WHO declared
on August 8, 2014 the West African EVD out-
break as a public health emergency of inter-
national concern (PHEIC). Under International
Health Regulations (2005), signatory govern-
ments like the Philippines are obliged to “de-
velop, strengthen and maintain public health
capacities for surveillance and response to be
able to detect, assess, notify and report events
and respond to a PHEIC.”
While the Philippines’ Department of Health
(DOH) has a robust surveillance system and
has experience in managing emerging and re-
emerging infectious diseases, the training was
in preparation for the possibility of introduction
of cases through travellers from affected coun-
tries and returning overseas Filipino workers.
The Research Institute for Tropical Medicine
(RITM), which is the DOH’s research institute
for infectious diseases, the WHO country of-
fice, and consultants employed by WHO as pri-
vate individuals or from Johns Hopkins Hospi-
MARCH 2015 NEWS 11
CONTINUED TO NEXT PAGE
tal and Tropical Health Solutions collaborated
to develop the curriculum and content of the
training.
The training was spread over three days of
workshops that consisted of 18 lectures and
10 practical or small group sessions, includ-
ing three practical sessions to put on and put
off personal protective equipment (PPE). Each
participant was given his own set of PPE ex-
cluding rubber boots to use during the work-
shop. PPEs are an essential part of controlling
the spread of EVD and protecting the health-
care workers involved in the care from falling
ill from EVD themselves. The lectures provided
participants with the knowledge base on Ebo-
la, detection and management, ethical issues
concerning clinical activities in EVD patients,
prevention and control, hospital waste man-
agement in relation to EVD, epidemic manage-
ment, laboratory procedures, biosafety and re-
ferral system.
Evaluation tools used in the training were
developed by WHO consultants and piloted on
RITM medical and nursing staff, and included
a pre- and post-workshop test, two evalua-
tion forms post-workshop and One Minute Re-
flections (OMR). The results of the evaluation
showed marked improvement in knowledge.
The participants’ median scores rose from sev-
en (7 correct answers out of 10 in the pre-test)
before the workshop to nine (9/10).
Similarly, confidence in safely caring for an
EVD patient rose markedly by the end of the
workshop. The percentage of participants who
disagreed or strongly disagreed with the state-
ment: “I am confident that I can be safe when
caring for a patient with Ebola virus disease,” fell
from 27.3 to 2.6 percent. Following the trend, the
percentage of participant who agreed or strongly
agreed with the statement rose from 32.5 to 87.2
percent.
The Department for International Develop-
ment UK funded the development an evaluation
of the training and employment of WHO consul-
tants; the DOH financed the conduction of the
training. The staff of RITM, DOH and WHO were
supported by their respective employers under
routine funding.
MARCH 2015 NEWS 12
Researchers to locally develop 3D-printed human organsDR MEL M BELUAN
T he Lung Center of the Philippines (LCP) in
collaboration with the Technological Insti-
tute of the Philippines (TIP) will be doing a study
on using genomics and three-dimensional print-
ing to create an artificial trachea for transplanta-
tion.
Signing a memorandum of agreement last
MARCH 18, researchers from LCP and TIP
would develop an interdisciplinary platform to
enable doctors to create a simple trachea, and
eventually more complex organs such as the
lungs, kidney and heart.
In a statement, LCP executive director Dr
Jose Luis J Danguilan said, “If we are success-
ful in its clinical applications, we may be at par
with the advanced nations in this new field ... an
artificial trachea could be made available in the
country in the next 3 to 4 years.”
The research, the country’s first, will come up
with 3D-printable biocompatible materials with
the help of TIP’s engineers. The technology
involves “weaving a bio-ink” using the nano-
technological concept of electrospinning which
mimics the web-spinning of spiders. After an or-
gan scaffold is built, it will be impregnated with
stem cells derived from the patient’s fat tissue or
bone marrow. The nascent “organ” will then be
allowed to incubate in a bioreactor. Prototypes
of the bioreactor and electrospinning device
were already developed by TIP researchers.
The technology’s biggest potential impact
would be helping to address the long lines of
would-be organ recipients looking for compat-
ible donors. Since this technology uses tissue
from autologous sources (ie, the patient’s own
stem cells), transplantation can occur without
donor-matching, organ shortage and immuno-
suppressive medication.
In a press release, TIP’s Dr Custer Deocaris,
a DOST Balik Scientist, described the scenario:
“In the near future, here in our own country, you
will visit the hospital and request your attend-
ing physician for the procedure. A complete
organ that looks like jell-o will be bio-printed by
a technician with a mere press of the ‘print’ but-
ton on a computer hooked-up to a 3D printer.
After you have provided stem cells, with either
a liposuction or a bone marrow extraction pro-
cedure, in just one week, your new organ is
ready for use.”
For years, researchers have been able to
3D-bioprint simple tissues such as tissues of
the skin, heart and blood vessels. In 2008, the
world’s first ever transplant of a more complex
structure, a bioengineered autologous trachea,
was performed by Dr Paolo Macchiarini in Swe-
den. Scientists in Australia and the US are now
trying to bioprint other organs.
MARCH 2015 FEATURE 14
Occupational medicine more relevant in today’s growing industries DR LOUELL L SALA
A s the country grapples with health and
safety issues associated with increasing
industrialization, occupational medicine (OM) is
becoming more important. In the recently con-
cluded second batch of the diplomate course
of the Philippine College of Occupational Medi-
cine (PCOM) held last MARCH 1, 2015 at the
Occupational Health and Safety Center (OSHC)
in Quezon City, 43 physicians from all over the
Philippines underwent training on regulations,
legislations, emerging Issues and common
practices in OM.
Overseen by the chair of the residency train-
ing program Dr Marilou D. Renales, the PCOM
diplomate course is conducted for doctors and
PCOM members who have completed the Basic
Course in Occupational Medicine (BCOM) and
with at least 2 years of active practice in OM.
Occupational medicine at a glanceIn an age when the worker’s health and safety
only becomes an issue after an incident, the oc-
cupational medicine specialty answered the call
of preventing work-related accidents and dis-
eases. Started in 1700 by an Italian physician,
Dr. Bernardino Ramazzini, who recognized the
relationship between lead and antimony and the
symptoms of poisoning in painters and other ar-
tisans,(1) OM has gone a long way in creating
a venue for management, the worker, and the
regulatory bodies of the government to meet.
In an effort to recognize that employment and
working conditions have powerful effects on
health equity,(2) the WHO urges member states
to connect health and labor, with emphasis
on primary prevention. And with this goal, the
Philippine College of Occupational Medicine
(PCOM) works hand in hand with the WHO and
other partners in the delivery of health services
for the workers.(3)
OM in the PhilippinesPCOM is the Institution accredited by the
Department of Labor and Employment (DOLE)
to conduct the Basic Occupational Safety and
Health (BOSH) and the diplomate course of OM.
Established in 1966,(3) it is a prime mover in the
preservation, promotion, protection, enhance-
ment of health, wellness, and safety of workers
in all occupations. It has been an active special-
ty accredited by the Philippine Medical Associa-
tion PMA and the Philippine Health Insurance
MARCH 2015 FEATURE 15
Corporation (PhilHealth).
Headed by national president Dr Oscar San-
tiano and vice-president Dr Gilbert Gille, PCOM
has 2500 members all over the country and is
growing. Presently, there are 23 chapters and
these are all organized to address the emerging
challenges in the practice of occupational medi-
cine in their respective areas.(3)
OM specialists are adept at creating policies
with regards to sickness absence, work-related
stress and work-related accidents. In the coun-
try where there are growing numbers of the
business process outsourcing (BPO) industries
employing young workers, all of which are ex-
posed to various health and safety hazards, the
function of the OM physician is crucial in ad-
dressing these issues. More than identifying the
different hazards in the workplace, OM special-
ists are also proficient at implementing Occupa-
tional Safety and Health (OSH) programs which
enhance productivity and contribute greatly to
national economic development efforts.
Important issuances on occupational safety and health
Rule 1960 of DOLE’s Standards of Occu-
pational Safety and Health requires every em-
ployer to provide in his workplace medical and
dental services, emergency medicines and den-
tal facilities. Hazardous workplaces with 100 to
199 employees only need to be serviced by a
part-time OM physician. Workplaces with 601 or
more employees require the full-time service of
an OM physician.(4)
Another group of very important issuances
which requires the specialization of OM physi-
cians deals with assisting the companies imple-
ment guidelines from DOLE. These guidelines,
which include drug-free workplace,(5) tubercu-
losis,(6) HIV/AIDS(5) and hepatitis,(5) have to be
translated into the policies of the company.
Bound by a common principle of ensuring
worker’s health, the protection and promotion
of health at work, the diplomate course of oc-
cupational medicine ensures that the physician
has the necessary competence in understand-
ing the complicated paradigm of worker, man-
agement, and the regulatory bodies of the gov-
ernment.
References 1. Mednet resources page. Medicine Network web-site. Available at http://www.medicinenet.com/script/main/art.asp?articlekey=18430. Accessed 15 March 2015. 2. WHO resources page. World Health Organization website. Available at http://www.who.int/occupational_health/publications/global_plan/en. Accessed 15 March 2015. 3. PCOM resources page. Philippine College of Oc-cupational Medicine website. Available at http://www.pcom.ph/about-us. Accessed. 15 March 2015. 4. OSHC resources page. Occupa-tional S afety and Health Center website. Available at http://www.oshc.dole.gov.ph/UserFiles/oshc2010/file/OSH_Standards_Amend-ed_1989_Latest.pdf. Accessed 15 March 2015. 5. OSHC resources page Occupational Safety and Health Center website. Available at http://www.oshc.dole.gov.ph. Accessed 15 March 2015. 6. OSHC re-sources page. Occupational Safety and Health Center website. Avail-able at http://cloud.eacomm.com/oshc2010/UserFiles/oshc2010/file/DO-73-05-Guidelines-for-Implementation-of-TB-Prevention-in-the-Workplace.pdf. Accessed 15 March 2015.
MARCH 2015 FEATURE 16
The depressed employee and the workplaceDR PAOLO L MENDOZA
“ Whatever happens today, it is because of
my girlfriend“
A call center agent posted the above and
jumped off the rooftop of the i2 Building, IT Park
Lahug, Cebu City last August 16, 2014. The
man committed suicide after his girlfriend had
broken up with him. As posted on his Facebook
account, he couldn’t accept the fact that she left
him “for no reason and that hurts me the most,
especially seeing her with other guys dancing,
laughing and having fun.”
Industrial and socioeconomic growth in the
Philippines means more and more workers are
subject to mental stress associated with work
and non-work activities. According to the Cen-
ters for Disease Control and Prevention, the
mental health of workers is an increasing con-
cern. Depression is estimated to cause 200 mil-
lion lost workdays each year at a cost to em-
ployers of USD17 to 44 billion.(1)
Studies have identified depression as a ma-
jor cause of disability, absenteeism, presentee-
ism and loss of productivity.(2-4) Despite the evi-
dence linking job stress and depression, there
is still predilection to allocate resources to gen-
eral medical care. This is further complicated
by the poor financial capacity of the employer.
There is limited data regarding evidence of ef-
fective intervention to prevent depression at
work.(5)
Workplace as hostile environmentDepression can affect anyone.(6) It is multi-
faceted in the workplace setting, primarily influ-
enced by factors such as neurotransmitters, ge-
netic predisposition, development of personality
traits and temperament, and gender.(7)
The US National Survey on Drug Use and
Health (2007) showed that rates of depression
vary by occupation and industry. Major depres-
sive episode was found in the personal care
and service occupations (10.8 percent) and the
food preparation and serving occupations (10.3
percent).(6) Common job stressors include high
job demands, low job control and lack of so-
cial support.(5) Work- and non-work-related risk
factors play a role in causing more job stress
which may contribute to depression.(6)
In the Gallup-Healthways Well-Being Index,
77 percent of workers across 14 major occupa-
tions have been identified of having a chronic
health condition (asthma, cancer, depression,
diabetes, heart attack, high blood pressure, high
cholesterol or obesity). The total annual costs
related to lost productivity totaled USD84 billion.
Burden to employersPatients with depression miss 4.8 workdays
and suffer 11.5 days of reduced productivity
within a 3-month period.(2) About 80 percent of
depressed persons reported functional impair-
ment, and 27 percent reported serious difficulties
in work and home life. Only 29 percent reported
MARCH 2015 FEATURE 17
contacting a mental health professional.(4)
Absenteeism is difficult to monitor, control
and reduce, as it is simultaneously a legitimate
and poor excuse for missing work. The occupa-
tional medicine physician should examine and
update existing organizational practices and
redefine aspects of job design to reduce stress
and decrease the risk of poor mental health.
In addition to direct costs, depression also
increases indirect costs by contributing to oth-
er costly conditions. According to Finch et al
(2005), an individual’s risk of depression is near-
ly doubled in the presence of type 2 diabetes
mellitus.(9) However, Campbell et al suggests
that 80 percent of patients with depression will
improve with treatment.(10)
Challenges to the behavioral healthcare system
Though employers recognize that behavior-
al health benefits are essential components of
health care, it is not customary to integrate it to
the health benefit plan for employees.(9)
Several issues complicate the behavioral
health care. In the Philippines, many health
maintenance organizations are limited in pro-
viding employees with the services of psychia-
trists and neurologists. As of late, consumerist
healthcare will continue to affect the delivery of
behavioral health care.(9)
Among the strategies that employers can
pursue include depression screenings; confi-
dential self-rating sheets; awareness programs;
depression recognition training; and access to
psychiatric services.(10) The Employer’s Guide
to Behavioral Health Services by Finch and
Philips provides information for the physician
and the employer in managing the employee’s
health status, productivity, and disability and
healthcare costs.(9)
References 1.. JAMA 2003 Jun 18;289:3135-3144. 2. Ann Intern Med 2001; 134: 345-360. 3. Geriatrics and mental health—the facts. Avail-able at: http://www.aagponline.org/prof/facts_mh.aspicon_out [ac-cessed Feb 17, 2015]. 4. NCHS Data Brief No. 7; 2008. Available at: http://www.cdc.gov/nchs/data/databriefs/db07.htm#ref08. [Ac-cessed Feb 17 2015]. 5. Preventing occupational disease and injury. 2nd ed. (2005). 6. Depression in the Working Population: Position Statement (2009). Available at: http://www.acoem.org/guidelines.aspx?id=5613 [Accessed Feb 17, 2015] 7. The NSDUH Report (2007). Available at:http://www.oas.samhsa.gov/2k7/depression/occupation.htmicon_out.[Accessed Feb 17, 2015]. 8. The causes and costs of absenteeism in the workplace. Available at: http://www.forbes.com/sites/investopedia/2013/07/10/the-causes-and-costs-of-absenteeism-in-the-workplace/. [Accessed Feb 17, 2015]. 9. An Employer’s Guide to Behavioral Health Services: A Road map and Recommendations for Evaluating, Designing, and Implementing Be-havioral Health Services (2005). 10. A Purchaser’s Guide to Clinical Preventive Services: Moving Science into Coverage (2006). Available at: http://www.businessgrouphealth.org. [Accessed Feb 17, 2015].
MARCH 2015 FEATURE 18
Filipino physicians provide appropriate initial management of patients diagnosed with acute coronary syndromeDR LEE EDSON P YARCIA
T he number one killer of Filipinos today are
cardiovascular diseases, but it is reassuring
to know that Filipino physicians are adhering to
the management guidelines for initial manage-
ment of patients with acute coronary syndrome
(ACS). In a multicenter descriptive study con-
ducted by Sinon and colleagues in 39 private
and government urban hospitals, physicians
at the ER were shown to comply with the 2007
American College of Cardiology/American Heart
Association (ACC/AHA) ACS guidelines for the
management of patients with unstable angina
(UA) /non-ST-segment elevation myocardial in-
farction (NSTEMI) and ST-segment elevation
myocardial infarction (STEMI). [Philipp J Intern
Med October-December 2014;52.]
A total of 1,398 eligible patients aged 18
years old and above were included in the study.
Up to 93 percent of patients had at least one car-
diac enzyme test done at the ER, with troponin
I being the most commonly requested. After di-
agnosis, 95.78 percent of patients received anti-
platelet therapy, the majority of whom received a
combination therapy of aspirin and clopidogrel.
As high as 98 percent of patients were then ad-
mitted in the hospital, while 26.68 percent were
considered to undergo percutaneous coronary
intervention.
The 2007 ACC/AHA guidelines recommend
obtaining an ECG and serum biomarkers for
patients presenting with classic symptoms of
ACS such as chest discomfort with or without
radiation to the arm, back, neck, jaw, or epigas-
tric pain. ECGs are important diagnostic tools
to provide management directions and clinical
prognosis. Biomarkers are important for estab-
lishing diagnosis. Cardiac troponins are the pre-
ferred markers because of their specificity and
sensitivity.
Moreover, the guidelines provide that man-
MARCH 2015 FEATURE 19
agement of UA/NSTEMI must be directed at
providing immediate relief of ischemia and pre-
vention of adverse outcomes. This is best ad-
dressed with anti-ischemic and anti-thrombotic
therapy. The guidelines suggest the use of aspi-
rin or a loading dose followed by a maintenance
dose of clopidogrel (300mg followed by a daily
dose of 75 mg). Patients who cannot tolerate
aspirin are given anticoagulant therapy such
as enoxaparin, bivalirudin or fondaparinux, and
this should be administered as soon as possible
after hospital admission. Invasive procedures,
such as percutaneous coronary interventions
may also be considered.
The study, published in the Philippine Jour-
nal of Internal Medicine, looked into records of
patients suspected of having ACS who were
brought to the ER. Seventy-six percent of pa-
tients were diagnosed with UA/NSTEMI, while
24 percent had STEMI confirmed with ECG and/
or cardiac enzymes results. Laboratory tests in-
cluded cardiac enzyme tests such as creatine
phosphokinase (CPK), CPK isoenzyme MB, tro-
ponin I and troponin T.
Upon diagnosis, more than 60 percent of
patients received combination of aspirin plus
clopidogrel, while 32.67 percent were started
with antiplatelet monotherapy. Aspirin was
given at a median total daily dose of 320mg,
while half of the total number of patients re-
ceived loading dose of clopidogrel. Around
86 percent of patients received anticoagulant
therapy, such as enoxaparin, fondaparinux, or
unfractionated heparin. Almost all the patients
(98 percent) were subsequently admitted
in the hospital, 66.03 percent of whom were
admitted in the critical care unit or intensive
care unit. Ninety one percent were referred to
a cardiologist, while 26.68 percent were con-
sidered to undergo percutaneous coronary
intervention.
The study shows that Filipino physicians,
across various specializations, use antiplatelets
and anticoagulants much frequently, in adher-
ence to the recent recommendations of the
ACC/AHA. This is important as medical organi-
zations or societies publish guidelines based on
best evidence to address the needs of patients.
The outcomes of patients presenting with ACS
are improved with adherence to generally ac-
ceptable approaches to diagnosis and manage-
ment.
“ ...it is reassuring to know that
Filipino physicians are adhering to
the management guidelines
for initial management of patients
with acute coronary syndrome”
MARCH 2015 FEATURE 21
A doctor-lawyer takes on medico-legal issues DR YVES SAINT JAMES AQUINO
D r Ivy Patdu remembered as a child that
she would say, depending on her mood,
she wanted to be a lawyer or a doctor, not know-
ing that in years to come she would actually be-
come both.
In 2002, Patdu graduated from the Univer-
sity of the Philippines-College of Medicine
(UPCM) under the Integrated Liberal Arts and
Medicine (INTARMED) program and got her
medical license that same year. Later on, Pat-
du would graduate from the Ateneo De Ma-
nila, School of Law and eventually passing the
bar after 2010.
“Most of the work I do actually involves both
medicine and law,” shared Patdu. At present, her
professional roles include being a legal consul-
tant for the Philippine Academy of Family Phy-
sicians, medico-legal officer for Asian Hospital
and Medical Center, and external consultant for
Legal Matters for the National Telehealth Center
in the University of the Philippines-Manila.
Idealism in childhoodAs a child, Patdu showed enthusiasm for
public speaking. To further develop her skills,
her father urged her to run for a position in the
Sangguniang Kabataan, the youth councils for
each barangay in the country. The original goal
was only to experience doing speeches during
the campaign period and to withdraw prior to
election day. There was a change of plan when
her family was told Patdu had a high chance of
winning. She stayed in the race and eventually
won a position as a councilperson.
“During this time, I was an idealist. I wanted
to fight for truth and justice,” wrote Patdu in one
of the personal essay she submitted during her
first year in law school. She explained that at the
time, her high-school classmates predicted that
she will become a lawyer and a human rights
advocate. “And so, I thought my purpose in life
was to be a lawyer,” she added.
While Patdu thought it was certain that she
would take up law in college, life offered another
alternative. She was accepted in the INTARMED
program of the UPCM, which allowed students
MARCH 2015 FEATURE 22
to finish medical school in seven years—two
years shorter than the more traditional track that
included four years of pre-med course and five
years of medical education. The program is also
deemed prestigious, accepting only 40 of the
best university applicants.
“The lure of the program was too big. As a
teenager, I became confused. Do I really want
to be a lawyer?” Patdu asked herself. She ex-
plained that she took this as a sign that she
needed to reconsider her original choice of tak-
ing up law.
With the support of her family, she realized
that being a doctor was much nobler than being
a lawyer, and that medical practice would allow
her to directly serve the people.
A period of introspectionBy the time Patdu was in the first year of med-
ical school proper (third year for the INTARMED
program), she started having serious doubts
about her academic track. She shared that one
of the organizations she joined was the UP Ma-
nila Debate Circle, making her realize that her
original passion for speaking and argumenta-
tion outweighed her interest to heal. Unlike her
zeal for philosophical and political debates, she
expressed disdain in having to study the anato-
my and physiology of the human body.
Despite her strong intentions to quit, she
decided to finish medicine and even enter a
residency program under the Department of
Otorhinolaryngology in the Philippine General
Hospital.
“Finally, during residency and after giving
medicine a try, I really was not happy,” added
Patdu.
After a period of introspection and inspired
reading of M. Scott Peck’s The Road Less Trav-
eled, Patdu decided to go to law school. “For
a year, I thought about it constantly and final-
ly I decided that I had to give my old dream a
chance,” wrote Patdu.
A combined practiceFew months after passing the bar examina-
tions in 2010, she started working as an associ-
ate lawyer in Solicitor General Estelito P. Men-
doza’s eponymous law firm. Patdu considers
Mendoza, a graduate of UP College of Law, as
her “mentor and inspiration.”
In her essay, Patdu cited Mendoza as an im-
portant example when she was convincing her
parents to allow her to go to law school. She
shared that the Solicitor General initially took a
pre-med course as an undergraduate but was
unhappy, eventually taking up law and becom-
ing one of the most celebrated lawyers in the
Philippines.
In the law firm, Patdu share that she was able
to realize her dream. She found her tasks inside
the courtroom the most challenging and also
the most enjoyable.
She admitted that working in the court did
not mean that she has stopped practicing medi-
cine, adding that her medical background helps
her a lot in her current work. Even as a law stu-
dent, she was naturally drawn to legal issues in
medicine. During her last year in Ateneo Law,
she wrote her juris doctor paper on “Hospital
Liability,” which received the dean’s award for
best thesis.
MARCH 2015 FEATURE 23
She also acknowledged that her medical
training taught her compassion, as well as
the value of hard work and perseverance. She
shared that it prepared her to accept that real
work would sometimes mean that you only get
a few hours of sleep. Patdu also explained it
taught her that learning is a life-long process,
which is important in both medicine and law as
the body of knowledge is quite dynamic, ever
changing and expanding.
In return, she also finds her legal back-
ground influencing her medical perspective.
Patdu admits that there are a lot of opportu-
nities to improve the medical practice in the
Philippines.
“The Medical Act of 1959 can be amend-
ed to be more responsive to current medical
practice,” shared Patdu. The medical act, also
known as Republic Act No. 2382, was meant
to establish standardization and regulation
of medical education, examination, licensure
and control of the practice of medicine in the
Philippines. A senate bill, known as the Physi-
cian’s Act of 2013, introduced by Senator Jing-
goy Ejercito Estrada is meant to upgrade the
medical act.
“Laws can be passed that promote a culture
of patient safety, and ways to improve hospital
processes to prevent or reduce medical errors,”
added Patdu.
Moving forwardAfter three years in the law firm, Patdu decid-
ed she needed to cut her work hours to take care
of her family, especially her two young children.
“I have assisted in controversial cases and
have learned valuable lessons while work-
ing there,” said Patdu. However, she said she
would prefer to start her own practice in order
to manage her own time and work closer to
home.
Last year, along with two other doctor-law-
yers, Patdu established the Patdu, Dimatatac
& Erfe Law Office in Muntinlupa City. “I’m still
learning .... The law practice is different in your
own firm versus being an associate in a law of-
fice,” expressed Patdu.
Despite her unorthodox and challenging
academic path, Patdu explained that she had
no regrets.
“Life is a journey,” said Patdu, emphasizing
the importance of exploring their options when
they are uncertain of they want to be or do in
life. “I think in the end, we all want to be happy,
and if your happiness is not in being a medi-
cal practitioner in the traditional sense, then
you deserve the chance to try and find it,” she
concluded
MARCH 2015 FEATURE 24
The Ludan method of hydration and other innovations: Dr Ludan’s legacy to pediatrics
DR MARIA KATRINA FLORCRUZ
D r Arturo Ludan’s journey started with a
single step that has treaded through a
thousand miles towards his goal of leaving a
lasting legacy to Philippine pediatric health-
care. An emeritus fellow of the Philippine Pedi-
atric Society (PPS) and recipient of numerous
awards, including The Outstanding Young Men
in 1977 and PPS Outstanding Pediatrician of
the Year 2014, he is well-known for his ground-
breaking work on diarrheal dehydration thera-
py and for coming up with the Ludan method
of hydration.
The first critical stepLudan’s pediatric practice has spanned
over 45 years. He is a graduate of the College
of Medicine – University of the Philippines (UP)
and completed his internship and first year of
pediatric residency at the Hospital of St Raphael
in New Haven, Connecticut.
“I took the first critical step when I took up pe-
diatrics… you have to make that career-defining
choice. Ano bang gusto mo talaga? Take pedi-
atrics and follow it through. In the process, try to
make your own skills, motivation and values,”
said Ludan.
He completed his training at Montefiore Hos-
pital and Medical Center in Bronx, New York
where he served as chief resident during his se-
nior year. It was in this same institution where
he met his mentor Dr Laurence Finberg, a world
renowned fluid and electrolyte physiologist.
Ludan recognizes the influence of Finberg on
his interest in pediatric fluid therapy. “I owe it to
him… I would not have been exposed to it [if not
for him]. “
Dr Arturo Ludan.
MARCH 2015 FEATURE 25
“As my mentor in Montefiore Hospital, he
taught me the tenets of fluid therapy which be-
came my subspecialty in pediatrics. That led me
to develop a simple and practical guide on fluid
therapy for maintenance, diarrheal dehydration
and dengue fever – the centerpiece of my lega-
cy to pediatric medicine,” he said.
Practical guide to fluid therapyHe returned to the Philippines in 1968 and
started his private practice with Capitol Medi-
cal Center. As an academician, he joined the
Department of Pediatrics of the UP-Philippine
General Hospital as clinical instructor and the
University of the East-College of Medicine as
professional lecturer.
He continued his work in fluid physiology and
was active in giving lectures on pediatric fluid
therapy of diarrhea, which would be later on rec-
ognized as the Ludan method.
The Ludan method of hydration calculates the
total fluid requirement per day of a child based
on body weight and is widely used by many phy-
sicians in treating dehydration due to diarrhea.
The fluid therapy includes the three therapeutic
phases – deficit, maintenance and replacement.
The deficit therapy corrects abnormal fluid
and electrolyte losses. Phase two or mainte-
nance therapy provides the daily normal losses
of fluid and electrolytes due to caloric expendi-
ture. Replacement therapy replenishes continu-
ing ongoing fluid losses due to conditions such
as vomiting and diarrhea.
The ORS formulationLudan also made notable contributions in the
improvement of the Oral Rehydration Solution
(ORS) in the Philippines when it was first intro-
duced by the WHO as oresol in the 1970s. “I
was hoping that the DOH will come out with the
right ORS. Oresol was the one with high sodi-
um, high osmolarity… I objected because I said
this [was] not safe for babies,” Ludan explained.
In 1978, while serving as the chairman of
the PPS Committee on Rehydration, he drafted
a position paper on the WHO oral rehydration
formulation, reiterating the concern on hyper-
Dr Ludan (left) during the awarding ceremonies for PPS Outstanding Pediatrician of the Year 2014, pictured here with one of his mentors, Dr Luis Mabilangan.
MARCH 2015 FEATURE 26
natremia and hyperosmolarity and suggesting
lowering the sodium level. “This position paper
was signed by the members of the PPS Board of
Trustees and was eventually forwarded to WHO
in Geneva,” said Ludan.
Thereafter, Ludan continued to give lec-
tures and workshops to promote the concept
and practice of oral rehydration therapy to
medical practitioners. He actively participated
in international fora on nutrition and diarrheal
diseases. He is also the author of several pub-
lications and wrote the chapter on fluid therapy
for the Philippine Textbook of Pediatrics and
Child Health, with Dr Fe del Mundo as the main
author.
Believing that the practice of medicine is a
dynamic process, Ludan continued his inter-
est in fluid and electrolyte therapy by develop-
ing a stepwise fluid management for dengue
fever (DF) and dengue shock syndrome (DSS).
In 2012, portions of this method were included
in the PPS-DOH National Guidelines in the fluid
management of DF/DSS.
Taking the road less travelledHe further ventured into the “road less trav-
elled” by being one of the first pediatricians to
integrate nutraceuticals, such as zinc and probi-
otics, in the management of diarrhea and atopic
dermatitis. “I want to develop my own method
and style of doing my practice… because of
these innovations, I was probably one of the
firsts to pioneer the use of probiotics,” said
Ludan.
He developed his interest in medical entre-
preneurship when he established the biologi-
cals distributor company Pedia-Aids, Inc. After
several years, he founded the pharmaceutical
company Pedipharma, Inc which specializes in
zinc preparations, saline nasal drops and nutra-
ceuticals.
Quality healthcare for allLudan thinks that there is a need to provide
medical coverage for all sectors of the society.
However, he also stressed the importance of
giving quality care.
“The intention of [the] government is to pro-
vide universal coverage… that’s in terms of the
quantity of healthcare. As to the quality of health
care, it’s a dynamic process because before we
can really achieve quality care, it requires train-
ing. These residents and practitioners should
adapt to high standards… And this is where the
PPS and other [medical] societies are involved...
the clinician is only as good as the training pro-
gram that he came from. If you come from an
institution that fails to comply with the standards
of care, then the quality of these practitioners
will suffer also,” said Ludan.
“It’s now up to the individual clinician to pos-
sess the qualification, the motivation and the
Dr Ludan with his wife, children and grandchildren.
MARCH 2015 FEATURE 27
values that are necessary to deliver these qual-
ity services. You have to possess the right at-
titude from the start. We [may] have everything
in place but if the clinician is not up to that, wala
din,” he added.
Recognizing mentorsLudan advises young doctors to follow the
mantra “A journey of a thousand miles begins
with a single step.”
“You have to start with an act which will guide
your career path. Take the road less travelled.
Be different but do not be indifferent to chang-
es. Do not follow the crowd. Create your own
career path and let others follow you. Develop
your own unique style of being an astute holistic
clinician,” he stated.
Moreover, he encourages doctors to be in-
quisitive, innovative, creative and research-
minded. “You don’t get fossilized and stunted
by what you learn in residency… you have to
continue enhancing, updating, improving,” said
Ludan.
Ludan reminds doctors who eventually be-
come successful to always look back. “Remem-
ber your mentors and role models. When I got
my PPS Outstanding Pediatrician [of the Year]
award, I recognized my mentors.”
“Dr Ludivina Garces-Holst, during my residen-
cy, instilled the importance of the right attitude.
Dr Finberg provided the knowledge and exper-
tise in fluid pediatrics. Dr Luis Mabilangan was
the epitome of love for teaching. Dr Perla San-
tos-Ocampo is a trailblazer of child advocacies.
Dr Fe del Mundo showed me that one should go
beyond one’s borders of comfort zone and serve
the community. Lastly, Dr Lino Ed Lim showed
me that to be an active pediatrician and at the
same time a business entrepreneur was doable,”
he said.
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ORGANIZING COMMITTEE
Many more distinguished overseas speakers to follow…
MARCH 2015 MARKET WATCH 29
Nutrilite stages health run
Capping its 80th anniversary celebration,
Nutrilite, the global health supplement
brand, held last MARCH 22 the Philippine leg of
the Nutrilite Health Run, a regional initiative ad-
vocating healthy living. The run already covered
Indonesia, Malaysia, Vietnam, Thailand, Austra-
lia and Singapore.
“Wellness has always been the Nutrilite ad-
vocacy ...Through this series of runs, we want
to encourage more people to put a premium
on their personal wellness,” said Leni Olmedo,
Country Manager of Amway Philippines, distrib-
utor of Nutrilite products.
The run kicked off at the Blue Bay Walk in Pa-
say City. The
run kit includ-
ed, among
others, Am-
way Expo ac-
cess stubs,
free member-
ship in Am-
way and a raf-
fle entry. Leg 2 of the race will be held on March 1,
2015 in Davao City. Leg 3 will be on March 15, 2015
in Cagayan de Oro City. Proceeds of the run will
go to the Amway One by One Campaign for
Children.
Philippine Heart Center holds cardiovascular intervention summit
In line with the 40th year celebration of the
Philippine Heart Center (PHC), its scientific
committee conducted a “Cardiovascular Inter-
vention and Innovation Summit” last MARCH
23 at the Dr. Avenilo Aventura Hall. Dr. Dy Bun
Yok, considered the father of interventional car-
diology in the Philippines, delivered the key-
note address on the historical development of
cardiovascular intervention.
The aim of this forum was to update the
knowledge of general cardiologists, inter-
nists, surgeons and cardiovascular tech-
nologists/technicians in the interventional
approach to the management of common
cardiovascular diseases. The various inter-
ventional pro-
cedures and
innovations cur-
rently available
for the manage-
ment of patients
with diverse
c a rd i o v a s c u l a r
disorders were
presented. This
summit also showcased the pioneering ef-
forts and achievements of PHC and its car-
diovascular specialists, and the Filipino
patients who benefited from these services.
Registration was free.
MARCH 2015 MARKET WATCH 30
PhilHealth conducts 2nd nationwide, simultaneous runs
I n celebration of PhilHealth’s 20th year in
MARCH 2015, PhilHealth successfully staged
a simultaneous run in NCR, Luzon, Visayas and
Mindanao primarily to promote and advocate
the benefits and it provides to its members. The
run’s carrier theme was the primary care ben-
efit package offered by PhilHealth or “TSeKaP”
(“Tamang Serbisyo para sa Kalusugan ng Pami-
lya”) to instill among target participants, particu-
larly those in the vulnerable sectors of society,
the importance of having a first line of defense
against costly hospitalization. Thus, the run is
dubbed “PhilHealth: Ready, TSeKaP, Go!”
At the same time, the run was intended to
showcase the
c o m p a n y ’ s
advocacy of
se l f l essness
as an organi-
zation, of in-
stilling gener-
HCWH-Asia joins first Zero Waste Fair
H ealth Care Without Harm-Asia (HCWH-
Asia), part of a global organization trans-
forming the health care sector through anti-in-
cineration advocacy and the promotion of green
and healthy hospitals, participated in the first
Zero Waste Fair, a highlight of the Zero Waste
Month. The exhibit was held from January 22
to24 at the Quezon Memorial Circle, Quezon
City.
HCWH showcased at the fair the successes
of three Philippine member-hospitals of Global
Green and Healthy Hospitals, a global cam-
paign of HCWH that represents the interest of
more than 9,700 hospitals and health centers
from six continents
that are committed
to reducing their
ecological footprint
and promoting en-
vironmental health.
The three hospitals,
the Philippine Heart
Center of Quezon City, St Paul Hospital-Tugueg-
arao and Maria Reyna Xavier University Hospi-
tal of Cagayan de Oro, exhibited their best prac-
tices to encourage other health care institutions
to implement proper health care waste manage-
ment.
osity, of welcoming every opportunity to share
resources for the improvement of the plight of
others.
The Philippine Health Insurance Corpo-
ration or PhilHealth was created in 1995 to
create a universal health coverage for the Phil-
ippines.
MARCH 2015 MARKET WATCH 31
The Medical City offers transradial catheterization
AstraZeneca Philippines forms coalition of medical specialists to fight cancer
A t The Medical City (TMC), interventional
cardiologists had utilized femoral artery
as the preferred route for coronary procedures
in the past years. The radial artery default ac-
cess for angiography and coronary intervention
at TMC was started in April 2010 by TMC con-
sultants Drs Sabas and Paolo Prado and since
then, has become the preferred access for coro-
nary procedures by most of the interventional
cardiologists.
Dr. Sabas cited the benefits of transradial
catheterization, which includes a lower risk of
bleeding at the incision site, less risk of ma-
jor complications
that require blood
transfusion or
surgery, and less
hematoma forma-
tion after the pro-
cedure. Transradial patients can move around
and walk to the bathroom after the procedure.
In the Philippines, TMC is one of the
first hospitals to offer transradial catheter-
ization. TMC Cath Lab currently uses tran-
sradial access in almost 90 percent of its
coronary procedures.
O NCOalition, created with the help of Aztra-
Zeneca, held its inaugural CME activity re-
cently at The Medical City hospital in Pasig City.
Involving cancer specialists and scientists, the
dinner symposium was entitled “The Future of
Oncology, Personalized Treatment and Patient
Care.” The coalition aims not only to recognize
current unmet needs in the optimal diagnosis
and treatment of leading cancer types such as
breast and lung cancers among Filipinos, but
also to emphasize the importance of biomarkers
and pioneering therapies.
AstraZeneca is privileged to partner with Fili-
pino cancer specialists in achieving our shared
goal of redefining cancer treatment, restoring
patients’ lives and eliminating cancer as a cause
of death,” said Gagan Singh, country president
of AstraZeneca Philippines.
“For 2015, ONCOalition will hold a series of
follow-up scientific discussions and major sym-
posia,” said Joshua Valencia, senior brand man-
ager, AstraZeneca Philippines.
Professor Richard L. PrinceSchool of Medicine and PharmacologyUniversity of Western AustraliaSir Charles Gairdner HospitalPerth, Western Australia
Bone fractures are the result of the interaction between external forces on the bone (e.g. falls), and the inherent bone strength. The integrity and strength of bone is maintained by the bone resorption-formation cycle, which regenerates the skeleton every 5 to 10 years. The decrease in bone mass and density characteristic of osteoporosis is a result of the gradual loss of cortical bone through net resorption. This deterioration can lead to an increased risk of fractures. One way to counter this deterioration is through calcium and vitamin D supplementation, which have favourable effects bone density and skeletal outcomes, particularly in elderly women.1-8
The role of calcium supplementationInitially, it was hypothesised that osteoporosis was a protein disorder, wherein osteoblasts fail to produce bone matrix. However, subsequent studies concluded that calcium-deficiency was an important factor in the development of osteoporosis leading to poor bone mineralisation and micro-anatomical deterioration.1
A 2-year randomised, placebo-controlled study has demonstrated that calcium supplementation can help reduce age-related bone loss in post-menopausal women.2 In the study, the subjects were randomised to receive one of four interventions: placebo, milk powder containing 1,000 mg of calcium, calcium tablets (1,000 mg/night), and calcium tablets (1,000 mg/night) plus an exercise regimen. Bone mineral density (BMD) at the lumbar spine, three hip sites, and two sites of the tibia close to the ankle joint were measured at 6-month intervals.
After the 2-year follow-up, it was found that calcium supplementation by either calcium tablets or milk powder prevented bone loss at the intertrochanteric hip site. Those who received placebo, calcium tablets, calcium and exercise, and milk powder reported a BMD percent-change of -0.81%, 0.17%, 0.23%, and 0.07% per year, respectively (p < 0.05 for all supplementation groups compared with placebo).
Synergy with vitamin DCalcium deficiency is not the only common nutritional deficiency that causes brittle bones. During the turn of the 20th century, rickets was a common problem especially in Europe. Rickets was later revealed to be a vitamin D-deficiency disorder. Osteomalacia, a similar disorder in adults (after epiphyseal closure), is characterised by poor bone mineralisation and is also mainly caused by vitamin D deficiency.3
Currently, the role of vitamin D in bone mineralisation is believed to be through promotion of gut calcium absorption, leading to an increase in extra-cellular calcium, a decrease in parathyroid hormone (PTH) levels, and a resulting decrease in bone resorption. The National Health and Nutrition Examination Survey (2004) revealed that an increase in serum 25-hydroxyvitamin D from 25 to 60 nmol/L was accompanied by a 5% increase in BMD.4 In contrast, in patients with low serum 25-hydroxyvitamin D, subclinical osteomalacia was commonly found by iliac crest bone biopsy.5
Evidently, the roles of calcium and vitamin D in promoting positive bone mineral balance are complimentary. A 5-year randomised, controlled, double-blind trial on 120 community-dwelling women aged 70 to 80 years was conducted to evaluate the effect of vitamin D added to calcium supplementation on hip BMD and other calcium-related parameters.6 Patients were randomised to receive one of three interventions: 1,200 mg/day of calcium with placebo; 1,200 mg/day of calcium plus 1,000 IU/day of vitamin D2; or double placebo (control). After the 5-year follow-up, only patients on calcium plus vitamin D supplementation had significantly better maintenance
of hip BMD compared with control (Table 1). Furthermore, combined supplementation reduced PTH at Year 3 and 5 vs control (p<0.005) in patients with baseline PTH levels above the median (3.6 pmol/L).
The positive effects of combined calcium and vitamin D supplementation translate to relevant patient outcomes. It has been demonstrated that in patients with a history of falling and vitamin D insufficiency living in sunny climates, vitamin D supplementation added to calcium was associated with a 19% reduction in the relative risk of falling, mostly during winter.7 Similarly, a randomised controlled trial showed that supplementation for 18 months with 1,200 mg of elemental calcium combined with 800 IU of vitamin D3, given to healthy ambulatory women living in nursing homes with a mean age 84 years , reduced the number of hip fractures by 43% (p=0.043), and the number of non-vertebral fractures by 32% (p=0.015) vs those on placebo.8 Furthermore, the incidence of hip fractures increased over time among those who received placebo, but remained stable in those who received calcium and vitamin D (Figure 1).
These results strongly indicate that calcium and vitamin D supplementation, especially in elderly women or others at high risk of osteoporosis, falls, or fractures, is beneficial in improving BMD and preventing adverse skeletal outcomes.
Calcium and cardiovascular riskDespite these demonstrated benefits, there is hesitation in some clinicians to actively recommend calcium supplementation. One of the main concerns arose from a 2008 randomised controlled trial suggesting that women on 1,000 mg of elemental calcium supplementation for 5 years had an increased risk of myocardial infarction (MI).9 However, it should be noted that the Kaplan-Meyer curve on time-to-first MI reported a p-value of 0.14 using log-rank test comparison.
A recently published study aimed to clarify the mechanisms underlying calcium-associated cardiovascular risk, particularly on its effect on atherosclerosis, the primary lesion associated with MI. This was an ancillary study of the Calcium Intake Fracture Outcome Study (CAIFOS) that evaluated the benefit of 5-year supplementation of 1,200 mg of elemental calcium. The ancillary study assessed common carotid artery intimal medial thickness (CCA-IMT) and carotid atherosclerosis at Year 3.10
Results of this ancillary study revealed that the multivariable-adjusted mean CCA-IMT of women randomised to calcium supplementation were not significantly different from women who received placebo.10 Furthermore, women who received calcium supplementation did not have increased carotid atherosclerosis (47.2% vs 52.7% with placebo; p=0.066) (Table 2). Interestingly, those in the highest tertile of total calcium intake had reduced carotid atherosclerosis compared with those in the lowest tertile (adjusted OR 0.70 [95% CI 0.51-0.96]; p = 0.028). The study concluded that these findings do not support the hypothesis that calcium supplementation increases atherosclerosis, and may even reduce surrogate cardiovascular risk factors.
Finally, a recently published meta-analysis on randomised controlled trials evaluated the cardiovascular safety of calcium supplementation (with or without vitamin D supplementation).11 The meta-analysis included 63,563 participants, and revealed that calcium supplementation with or without vitamin D supplementation, did not significantly increase coronary heart disease events (RR 1.02; 95% CI 0.96, 1.09; p=0.51), all-cause mortality (RR 0.96; 95% CI 0.91, 1.02; p=0.18); and MI (RR 1.08; 95% CI 0.92, 1.26; p=0.32). Heterogeneity among the trials was low (I2 = 0%).
Unlike in clinical trials, a one-size-fits-all approach cannot be implemented in actual clinical practice. The management of a post-menopausal woman with low serum vitamin D would be different from that of a 30-year old woman with no known risk factors. Patients at greater risk should receive more proactive management.
In summary, calcium and vitamin D supplementation increases bone density, particularly in elderly women. This improvement translates to better skeletal outcomes by reducing fractures and falls in these patients. There is weak evidence behind concerns of increased cardiovascular risk associated with calcium supplementation. For those at high risk of adverse skeletal outcomes, calcium and vitamin D supplementation is warranted.
References: 1. Nordin BEC. Nutrition 1997;13:664–686. 2. Prince R, Devine A, Dick I, et al. J Bone Miner Res 1995;10:1068-1075.3. Bhan A, Rao AD, Rao DS. Endocrinol Metab Clin North Am 2010;39:321-331.4. Bischoff-Ferrari HA, Dietrich T, Orav EJ, Dawson-Hughes B. Am J Med
2004;116:634-639.5. Priemel M, von Domarus C, Klatte TO, et al. J Bone Miner Res 2010;25:305-312.6. Zhu K, Devine A, Dick IM, Wilson SG, Prince RL. J Clin Endocrinol Metab
2008;93:743-749. 7. Prince RL, Austin N, Devine A, et al. Arch Intern Med 2008;168:103-108.8. Chapuy MC, Arlot ME, Duboeuf F. N Engl J Med 1992;327:1637-1642.9. Bolland MJ, Barber PA, Doughty RN. BMJ 2008;336:262-266. 10. Lewis JR, Zhu K, Thompson PL, Prince RL. J Bone Miner Res 2014;29:534-541.11. Lewis JR, Radavelli-Bagatini S, Rejnmark L, et al. J Bone Miner Res 2015;30:165-
75.
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The Calcium and Vitamin D Controversy: an Update from the Endocrine AngleCalcium deficiency is an important factor in the development of osteoporosis. In a sponsored symposium supported by the International Osteoporosis Foundation and Pfizer Consumer Healthcare, Professor Richard L. Prince reviewed the evidence demonstrating the benefits of calcium and vitamin D supplementation on bone density and skeletal outcomes in the management of osteoporosis, and recent data confirming the cardiovascular safety of these interventions. The symposium was part of the International Osteoporosis Foundation Regional 5th Asia-Pacific Osteoporosis Meeting, held from 14 to 16 November 2014 at the Taipei International Convention Center, Taiwan.
Table 1. Effect of combined calcium and vitamin D supple-mentation on hip BMD and bone-related biochemistry (% difference vs control)6
Year 1 Year 3 Year 5
Hip BMD 1.2 ± 0.6% (p=0.04)
2.8 ± 1.1% (p=0.01)
2.2 ± 1.1% (p=0.05)
Plasma alkaline phosphatase concentration
-11.3 ± 2.9% (p<0.001)
-8.7 ± 3.9% (p=0.03)
-11.3 ± 5.7% (p=0.05)
Urinary deoxypyridinoline-to-creatine ratio
−34.5 ± 8.6% (p<0.001)
−16.3 ± 8.0% (p=0.05)
−27.6 ± 8.6% (p=0.002)
Plasma calcium concentration
1.8 ± 0.7% (p=0.01)
2.6 ± 0.8% (p=0.001)
NS*
BMD, bone mineral density; NS, not significant.*Data not published
Table 2. Intention-to-treat and per-protocol odds ratios for the presence of common carotid artery atherosclerosis according to randomization for calcium supplementation at baseline.10
Intention-to-treat
Placebo Calcium P-value
Unadjusted 1.0 0.80 (0.63-1.02) 0.066
Multivariate adjusted 1.0 0.80 (0.6-1.04) 0.095
Per protocol
Placebo Calcium P-value
Unadjusted 1.0 0.73 (0.54-0.97) 0.033
Multivariate adjusted 1.0 0.74 (0.54-1.02) 0.064
0
10
20
30
40
50
60
70
80
0-6 months 6-12 months 12-18 months
Placebo
Calcium + Vit. D
Incid
ence
(no.
/1,0
00/y
ear)
p=0.007
45 47
66
38 37 39
Figure 1. Incidence of hip fractures among elderly women treated with vitamin D plus calcium vs place-bo, according to length of follow-up.8
Dear Friends and Colleagues from the Region,
The time has come for us to convene for an update on ObGyn ultrasound. Please come join us at the 11th ISUOG-Outreach 2015 in Singapore, on Sunday 3rd May to Tuesday 5th May 2015. The venue will be a new iconic building for diagnostics, research and healthcare education – The Academia on Outram (Singapore General Hospital) Campus, 20 College Road.
The theme of this meeting is “Defining Contemporary Office Investigations – Closing the gap between ultrasound, laboratory tests and your practice”.
The past decade witnessed an explosion of science and medical knowledge surrounding the ObGyn practice. Many routine tests have gone molecular; point of service imaging has become very sophisticated; reports of tests utilising sophisticated bioinformatics algorithms land on our clinic desk daily. While some of these routine tests and imaging in our clinics are expensive and the technology intimidating, this meeting guides you to the tests best suited for your clinical needs.
We cordially invite you to come to this occasion where leading international speakers in the academic world reach out to the ObGyn communities in this region. Last year, the 10th ISUOG-Outreach 2014 has been socially and academically stimulating as we were joined by an excess of 550 delegates, 25 overseas and 42 local speakers, to celebrate the 10th anniversary of this meeting. The 11th ISUOG-Outreach is looking to be equally enriching. We hope to welcome many of you to Singapore come May 2015.
Yours Sincerely,
George SH YeoChairman
Tan Hak KoonCo-chairman
11th International Society of Ultrasound in Obstetrics & Gynecology Outreach Course (ISUOG-OR) 2015in conjunction with 6th Scientific Congress of College of Obstetricians & Gynaecologists, Singapore (COGS) 2015
Brought to you by
College of Obstetricians & Gynaecologists, Singaporeisuog.org
Defining Contemporary Office Investigations Closing the gap between ultrasound, laboratory tests and your practice3 – 5 May 2015The Academia @ Outram Campus (Singapore General Hospital) Singapore
Scan QR Code to visit event website
REGISTER ONLINE NOW AT www.isuog-or.comEnjoy Early Bird Rate from 1 Jan – 15 Mar 2015
Normal Rate applies thereafter. Hurry - registration closes on 14 Apr 2015BE PART OF THE 11th ISUOG-Outreach & 6th Scientific Congress of COGS 3 – 5 May 2015 @ The Academia on SGH Outram Campus, Singapore
…MORE TO COME – COME JOIN THE COURSE AS A LEADING FACULTY CONGREGATES HERE IN OUR REGION!Latest programme, updates and online registration at
www.isuog-or.com
BENOIT BernardFrance
CHAOUI Rabih
Germany
EVANS MarkUSA
HYETT Jon
Australia
MALINGER GustavoIsrael
JAPARAJ Robert Peter
Malaysia
MURAKOSHI TakeshiJapan
KIM Gwang Jun
Korea
LEUNG Kwok Yin
Hong Kong
POON Leona
UK
VILLE Yves
France
WON Hye Sung
Korea
SHIH JinchungTaiwan
SALOMON LaurentFrance
Invited Faculty of the 11th ISUOG-Outreach Course & 6th Scientific Congress of College O & G, Singapore 3 – 5 May 2015
MARCH 2015 NEWS 35
ICU patients may benefit from assistive communication toolsCHUAH SU PING
Half of patients in intensive care units
(ICUs) who are on ventilators to help them
breathe, could benefit from assistive communi-
cation tools, a new study has revealed.
In the study, 53.9 percent of the 2,671 me-
chanically ventilated patients screened met
basic communication criteria and could po-
tentially benefit from the use of assistive com-
munication tools and speech language con-
sultation. These tools could be as simple as
a notepad and pen that may allow a patient
to write requests and questions. Patients who
were eligible for the study were those who
were awake, alert and responsive to verbal
communication from clinicians for at least one
12-hour nursing shift, while receiving mechani-
cal ventilation (MV) for 2 or more consecutive
days. [Heart Lung 2015;44:45-49]
“Our findings challenge the commonly held
assumption of many clinicians and research-
ers that these patients are unable to communi-
cate or participate in their care,” said Dr. Mary
Beth Happ, co-author of the study, and distin-
guished professor of nursing at The Ohio State
University, Columbus, Ohio, US. The study,
which involved six specialty ICUs across two
hospitals in an academic health system found
that the lowest proportion of MV patients who
met communication criteria were from the Neu-
rological ICU (40.8 percent), while the highest
proportion was from the Trauma ICU (70 per-
cent).
“Establishing lines of communication is the
first step in a patient being able to make his
or her needs known and have accurate symp-
tom assessment and management, and con-
tributes to an overall better patient experience.
We know from interviews with patients who re-
member their critical care experience that the
inability to communicate is anxiety producing
and, in some cases, terrifying,” said Happ.
Dr. Augustine Tee, chief and senior consul-
tant at the Department of Respiratory and Criti-
cal Care Medicine at Changi General Hospital
(CGH), Singapore, agreed on the importance
of improving communication during critical
care. “As intensivists, we are now paying more
attention to avoid oversedation of mechani-
cally ventilated ICU patients, as research has
shown that a more awake and participative
ICU patient has a better prognosis in terms of
recovery,” he said.
“As such, for an ICU patient to be able to
interact with ICU staff via various communica-
MARCH 2015 NEWS 36
tion aids is a natural development accompany-
ing reduction in sedative medication use,” said
Tee. He highlighted that CGH utilises innova-
tive assistive communication tools in its ICUs,
such as the award winning ICU Patient Care
Communicator App which has various features
to help patients communicate with caregivers
and family members.
Using an electronic tablet that is brought
bedside, patients are able to use the app to
indicate via words and pictures, their physical
and emotional needs. The app also enables
patients to communicate by sketching or writ-
ing simple words. Additionally, the app in-
cludes a pain management chart which allows
patients to convey the level of pain they are
experiencing in various parts of their body. The
app, which features translation capabilities in
19 different languages, was developed by the
Society of Critical Care Medicine (US). [The
Society of Critical Care Medicine; ICU Patient
Communicator App. Available at www.sccm.
org/News/Pages/ICU-Patient-Communicator-
App.aspx. Accessed on 27 January 2015]
MARCH 2015 NEWS 37
Excess body weight linked to higher risk of cancerCHUAH SU PING
High body mass index (BMI), defined as 25
kg/m2 or greater, is associated with an in-
creased risk of cancer, according to a study in-
volving data from 184 countries.
According to the population-based study,
481,000 or 3.6 percent of all new cancer cases
in adults in 2012 were attributable to high BMI.
Population attributable fractions (PAFs) were
greater in women than in men (5.4 versus 1.9
percent). Corpus uteri, postmenopausal breast
and colon cancers accounted for 63.6 percent
of cancer attributable to high BMI. The investi-
gators also noted that a quarter (approximately
118,000) of the cancer cases related to high BMI
in 2012 were probably due to the increase in
BMI since 1982. [Lancet Oncol 2015;16:36-46]
“Data from Singapore were analysed as
part of the Southeast Asia geographic region.
Overall, the risk of obesity-associated cancer is
somewhat lower in Southeast Asia compared
with the global average,” said Dr. Wong Seng
Weng, medical director and consultant special-
ist in medical oncology at The Cancer Centre
(a Singapore Medical Group Clinic). He noted
that globally, obesity contributed to 1.9 percent
of newly diagnosed cancer in men and 5.4 per-
cent in women. “The corresponding figures for
Southeast Asia were 0.5 percent for men, and
2.2 percent for women.”
“The reason for this difference is that North
America and Europe have higher incidences of
high BMI and are responsible for two-thirds of
the global incidence of obesity-related cancers,”
said Wong. However, the rise in obesity rate has
slowed in North America but continues to rise in
regions such as Southeast Asia. In other words,
while Singapore with other Southeast Asian
countries is in a better position today than North
America, our advantage is likely to erode over
the next decades.”
Wong noted that this study is important as it
showed the huge cancer burden, with half a mil-
lion of new cases yearly contributed by obesity.
“On top of that, it demonstrated a trend – the in-
cidence of being overweight has increased by
about a quarter worldwide over the last three de-
cades. This effect alone has contributed 120,000
new cases of cancer yearly worldwide. This trend
is going to accelerate with globalisation and
economic development in the developing world
where the bulk of the world population reside.”
Obesity plays a promoting roleWith regards to how obesity contributes to
MARCH 2015 NEWS 38
cancer risk, Wong noted that it is unlikely that
obesity by itself initiates the process of carcino-
genesis. “Rather, obesity plays a promoting role,”
he said. “Excess body weight has been associ-
ated with an increase in oestrogen as adipose
tissue contains an enzyme known as aromatase,
which is responsible for aromatising circulating
androgen in the body into oestrogen. Several
cancers in women such as breast cancer and en-
dometrial cancer are known to be related to the
stimulation by oestrogen.”
“An excess body weight also increases the
body’s resistance to the effect of insulin in the reg-
ulation of serum glucose level. Excess produc-
tion of insulin and related substances known as
insulin-like growth factors promotes cell growth
including cancer cells,” said Wong.
Wong noted that while patients who have not
suffered from cancer should be counselled on
appropriate weight management (if they are over-
weight), it is important to also educate patients
and their families that the weight issue should not
be tackled during the acute phase of anti-cancer
therapy. “During cancer treatment, paradoxically,
measures are necessary to prevent excessive
weight loss leading to weakening of the body and
compromising the patient’s ability to complete
the prescribed treatment course.”
“For certain cancers, for instance breast can-
cer in post-menopausal women, factors such as
obesity, high fat and low fibre diets, and a lack of
exercise are constantly associated with a higher
risk of relapse following potentially curative treat-
ment in clinical studies,” said Wong.
MT(PH-REG)MAR2015-FINAL.indd 18 24/2/15 3:38 pm
• EFFECTIVE and WELL TOLERATED• TARGETS PAIN and INFLAMMATION
• EFFECTIVE and WELL TOLERATED • TARGETS PAIN and INFLAMMATION •
MARCH 2015 NEWS 39
Chronic fatigue syndrome redefinedJENNY NG
A committee report on chronic fatigue syn-
drome developed by the US Institute of
Medicine (IOM) is hoping to educate physicians
on the seriousness of the condition with a new
name and new diagnostic criteria.
The committee suggested renaming chronic
fatigue syndrome as systemic exertion intoler-
ance disease (SEID) to more accurately reflect
the complexity of the condition. To receive a di-
agnosis of SEID, patients would have to have
each of the following four symptoms:
1. A substantial reduction or impairment in
the ability to engage in pre-illness levels of oc-
cupational, educational, social, or personal ac-
tivities that persists for more than 6 months and
is accompanied by fatigue, which is often pro-
found, is of new or definite onset (not lifelong), is
not the result of ongoing excessive exertion and
is not substantially alleviated by rest;
2. Postexertional malaise;
3. Unrefreshing sleep; and
4. Cognitive impairment or orthostatic intoler-
ance
“Our goal is to facilitate diagnosis,” said
Committee Chair Dr. Ellen Clayton of the
Vanderbilt University, Nashville, TN, US. “We
hope these evidence-based diagnostic cri-
teria provide a new foundation for future re-
search regarding cause and treatment.”
The report was commissioned by the US
Department of Health and Human Services,
National Institutes of Health, US Social Secu-
rity Administration, US FDA, US CDC, and the
Agency for Healthcare Research and Quality
to develop evidence-based clinical diagnostic
criteria for SEID for use by clinicians.
One difficulty in diagnosing SEID is the yet
unknown aetiology of the disease. Diagnosis
is therefore based on the identification of core
symptoms, the most prominent being exces-
sive postexertional fatigue that can severely
limit a person’s ability to function in day-to-
day life.
According to Clayton, these symptoms
can often be met with skepticism from physi-
cians. However, the panel found compelling
evidence for impairment, especially in the
characteristic decrements seen after 2-day
cardiopulmonary testing, the clear and re-
producible findings of orthostatic intolerance,
and evidence of slowed processing based on
neuropsychiatric test data.
The committee further detailed an algo-
rithm for diagnosis, providing an extensive list
of findings on patient history, physical exami-
nation, and symptom-based tests, to be used
along with the new criteria.
“We emphatically do not want clinicians to
do all the objective tests we identify. They’re
MARCH 2015 NEWS 40
expensive, onerous, and not uniformly avail-
able,” noted Clayton. “Often you can get most
of what you need from the history and physi-
cal examination.”
Symptom-based treatment is recommended
to begin as soon as the symptoms are identi-
fied. Committee member Dr. Peter Rowe of the
Johns Hopkins Children’s Center in Baltimore,
MD, US, added, “We’ve got good treatment al-
gorithms for things like headaches, sleep dis-
turbance, and certain [other] kinds of pain. No
one treatment is appropriate for every person,
but there’s much out there that’s helpful and
available [to clinicians].”
Comparisons in the treatment of heel painAn expert in Sports and Rehabilitation Medicine discussed modalities in the
treatment of athletic injury during the 4th Asia-Oceanian Conference of Physical
and Rehabilitation Medicine, held at the Plaza Athenee in Bangkok, Thailand,
last December 12, 2014.
Sports injuries in the Philippines comprise
36% of trauma seen daily in the ER. There
is an equal distribution across age groups.
As people are becoming more athletic, more
injuries may also happen.1 Sports injuries
among those 65 and older have increased by as
much as 50 percent in the last 20 years. Among
people 75 and older, sports-related injuries in-
creased by 29%.2
Most injuries are characterized by heel pain,
it is experienced by 85-90% of the population.
This heel pain may be calcaneal tendonitis and/
or plantar fasciitis patients, with only 30% of
patients having no athletic activity. Tendinopa-
thy is common among athletes participating in
racquet sports, track and field, volleyball and
soccer. However, the condition may also be ex-
perienced by non-athletes. The basic symptom
of tendinopathy is pain. It usually occurs at the
commencement and end of a training session.
Pain may also occur during exercise, as pathol-
ogy progress, even interfering with activities of
daily living. There may be an acute phase, when
the tendon is diffusely swollen and tenderness
on palpation is usually greatest 2–6 cm proxi-
mal to the tendon insertion. There may also be
palpable crepitations. A tender, nodular swell-
ing may be commonly present in chronic cases
signifies tendinosis. Diagnosis of tendinopathy
is based mainly on history and detailed clinical
examination. However, diagnostic imaging may
be requested to exclude other musculoskeletal
disorders. Conservative management with oral
or topical anti-inflammatory medications is em-
ployed. Physiotherapy and stretching exercises
Prof. BFD Valdecanas
MEETING HIGHLIGHTS 42
are also usually done.1
Research on different methods of enhancing
transdermal delivery of specific drugs aimed
for systemic and/or local effect. The main goal
was to facilitate absorption from the skin to the
site of pain.3 One of these many methods of
transdermal medication delivery is phonopo-
resis. It is used in pain and anti-inflammatory
management by employing ultrasound waves
to enhance fast absorption of therapeutic sub-
stances through the skin. In phonoporesis,
special sound waves above the audible limit of
20kHz are utilized.4
Literature is not lacking about the use of ul-
trasound for better delivery of medications. Gel-
based substances showed 80% better absorp-
tion, compared with water-based preparations.4
Examining effects of ultrasound in the clinical
setting,5-8 results showed ibuprofen with phono-
poresis and plain ultrasound were both effec-
tive in 10 sessions.6 Ketoprofen with ultrasound,
showed increased level of ketoprofen in the
non-fatty tissue of the knees (synovium) com-
pared with serum levels. Subcutaneous tissues
may serve as a reservoir of ketoprofen.7,8
A double-blind, multi-operator, single-
center prospective study was done with 150
participants to compare the efficacy of ke-
toprofen phonophoresis and conventional
plain ultrasound in the treatment of heel pain.
Pulse therapy was used. Improvement in
functional assessment scores was obtained
from pre-treatment questionnaire to post-
treatment survey.9 Improvement in pain per-
ception was also measured using the visual
analog scale (VAS).10 The participants who
were included in the research had the follow-
ing characteristics: diagnosed with calcaneal
tendonitis, plantar fasciitis, or both; has uni-
lateral affectation; without nerve entrapment
syndromes; without post-traumatic arthri-
tis; without hypersensitivity to ketoprofen or
other non-steroidal anti-inflammatory drugs.11
Results demonstrated that VAS scores
were improved in the phonophoresis group.
(Figure 1) Moreover, results showed that ke-
toprofen has triple action effect. There was
faster absorption and superior diffusion of the
Figure 1. Graph of VAS scores per treatment session
90
67.5
45
22.5
0
Treatment 1 Treatment 2 Treatment 4 Treatment 6 Treatment 8
Ketoprofen Phonophoresis Plain Ultrasound
VAS Scores(0-100mm)
Figure 2. Graph of scores in Functional assessment
100
75
50
25
0Ambulation ADLs Sports Total
Functional Scoring(FAAM)
Ketoprofen Phonophoresis Plain Ultrasound
MEETING HIGHLIGHTS 43
active substance at the inflammation site. This
may be due to ketoprofen being concentrated
in the synovium, more than in fatty tissue and
serum, after phonophoresis.12 There was also
high tissue concentration level only at the pain
site, thus minimizing systemic side effects.
Even functional assessment scores showed
improvement in the ketoprofen phonophoresis
group.10 (Figure 2)
With the results, it is recommended that fur-
ther analysis of data may be done (i.e., differ-
ence in response between males and females,
specific diagnoses and response to intervention
may be scrutinized). Furthermore, additional
subsets may be included (e.g., ketoprofen gel
application with sham ultrasound). Serum level
References: 1. Maffulli N, et al. J R Soc Med 2004;97:472–476. 2. Annual Cen-sus, Cardinal Santos Memorial Medical Center. 2014. 3. Byl NN. Phys Ther 1995;75(6):539-53. 4. Cameron MH, et al. Phys Ther 1992;72(2):142-8. 5. Klaiman MD, et al. Med Sci Sports Ex-erc 1998;30:1349-1355 6. Kozanoglu E, et al. Swiss Med Wkly 2003;133(23-24):333-8. 7. Rolf C, et al. J Rheumatol 1997;24(8):1595-8. 8. Coaccioli S. Eur Rev Med Pharmacol Sci 2011;15(8):943-9. 9. Martin RL, et al. Foot Ankle Int 2005;26(11):968-83. 10. Valdecanas B, et al. Phil J of Surg & Surg Specialties 2014. 11. Wolgin M, et al. Foot Ankle Int 1994;15(3):97-102. 12. Cagnie B, et al. Phys Ther. 2003;83(8):707-12.
determination may also be done, as well as stan-
dardization of the protocol in terms of amount of
gel used.
CONCLUSIONKetoprofen phonophoresis afforded better
relief from inflammatory heel pain as compared
with plain conventional ultrasonic modality.
MEETING HIGHLIGHTS 44
MARCH 2015 CALENDAR 45
M A R C H
2015 Wonca Asia Pacific Regional Conference4/3/2015 to 8/3/2015Taipei, TaiwanInfo: Wonca Taipei 2015 SecretariatTel: +886-2-2766-5367Fax: +886-2-2756-3323Email: [email protected]: www.wonca2015taipei.com
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World Congress of Nephrology (WCN) 201513/3/2015 to 17/3/2015Cape Town, South AfricaInfo: International Society of NephrologyTel: (32) 2 808 71 81Fax: (32) 2 808 4454Email: [email protected]: www.wcn2015.org
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MARCH 2015 EXPERT OPINION 48
Electronic cigarettes could be one of the biggest public health opportunities of our
time, but that depends on who you talk to. They have been shown to be effective in
helping smokers quit and many believe them to be much safer than cigarettes. But the
debate rages on.
E-cigarettes help smokers quit, ban reflex and ‘no harm’ perception must be challenged
SCICOM – MAKING SENSE OF SCIENCE
Electronic cigarettes could be one of the big-
gest public health opportunities of our time,
but that depends on who you talk to. They have
been shown to be effective in helping smokers
quit and many believe them to be much safer
than cigarettes. But the debate rages on. At the
2015 American Association for the Advance-
ment of Science (AAAS) Annual Meeting held
recently in San Jose, California, US, a panel of
global advocacy, ethical, policy, health, toxicol-
ogy and industry experts from Germany, New
Zealand, South Africa, the UK and US debated:
are electronic cigarettes killing me softly or our
greatest public health opportunity?
E-cigarettes are already used by tens of mil-
lions of smokers around the world. Hundreds of
versions are available online or in specialised
shops. Analysts at Wells Fargo (2013) predict
that sales will outstrip classical cigarettes by
2021. These battery-powered devices work by
delivering aerosol (vapour) containing nicotine
to the user. The apparent medical advantage is
that the vapour produced contains compounds
in the tens to hundreds compared with the 8,600
or more produced in cigarette smoke that cause
life-threatening diseases.
The American Cancer Society estimates that:
• One billion people smoke cigarettes and
the number is increasing.
• Half of cigarette users will die early because
they smoke.
• Six million people die every year because of
tobacco. This figure includes 5 million smokers,
but also about 600,000 non-smokers exposed
to second-hand smoke.
• It is expected that, without action, 8 mil-
lion people will die annually of tobacco-relat-
MARCH 2015 EXPERT OPINION 49
ed causes, by 2030. Over 80 percent of these
deaths will be in low- and middle-income coun-
tries.
• Non-communicable diseases (NCDs) kill
35 million people annually, 80 percent of which
are in low-and middle-income countries. Tobac-
co is responsible for one out of six NCD deaths.
The most recent study undertaken by an in-
dependent authority, The Cochrane Collabora-
tion, and published in December 2014 suggests
that e-cigarettes have a significant role to play
in helping smokers reduce or quit. [Cochrane
Database of Systematic Reviews 2014, Issue 12.
Art. No.: CD010216. DOI: 10.1002/14651858.
CD010216.pub2] This independent network in-
cludes researchers, health professionals and
consumers of healthcare, carers, advocates and
people interested in health from 120 countries.
It also backs third-party research meeting the
high standards it sets. In this Cochrane Review,
two randomised trials were conducted with a to-
tal of 662 current smokers. Admittedly, the num-
ber of studies included was quite small, so the
evidence is not yet strong. However, it did find
that about 9 percent of smokers who had used
electronic cigarettes were able to stop smok-
ing for up to 1 year. This compares with around
4 percent of smokers who used nicotine-free
placebo electronic cigarettes. Among smokers
who had not quit, researchers found that 36 per-
cent of electronic cigarette users reduced their
consumption of tobacco cigarettes by half. This
compared with 28 percent of users who were
given placebos.
Speaker and chief executive of Action on
Smoking & Health UK (ASH) set up by the Royal
College of Physicians, Deborah Arnott, spoke in
favour: “Cochrane reviews are world renowned
for their systematic analysis of the evidence and
our findings at population level are consistent
with their conclusions that electronic cigarettes
have the potential to help smokers quit. Re-
search by ASH over the last 5 years has now
been supplemented by official UK government
statistics to show that almost no one who is not
a smoker is regularly using e-cigarettes. Neither
is there evidence thus far from the UK that the
growth in e-cigarette use is leading to an in-
crease in smoking, particularly among young
people, in fact smoking rates continue to fall.
Continued surveillance is clearly needed, as is
a considered and objective approach from pol-
icy-makers who have very mixed views on what
to do about regulation which is all too often in-
formed by prejudice rather than the evidence.
There is a danger that the precautionary prin-
ciple is being used to deny smokers access to
products which can save their lives. Over 1,000
people will die worldwide from tobacco during
this 90 minute session alone. E-cigarettes have
the potential to dramatically reduce this deadly
toll.”
Speaker and deputy director of the US Na-
tional Institute on Drug Abuse (NIDA), Dr. Wil-
son Compton advocated the middle ground:
“Electronic nicotine delivery systems have both
promise and concern. Let’s remember that
cigarette smoking causes one in five deaths in
the US every year. Every approach to reducing
cigarette smoking should be considered, and
e-cigarette use by smokers attempting to quit
is promising. Nevertheless, advances in brain
MARCH 2015 EXPERT OPINION 50
and gene research are showing that adolescent
exposure needs closer attention. Nicotine is ad-
dictive and addiction is a developmental disor-
der with an abuse trajectory that predominantly
starts in one’s youth. And addiction has its dark
sides. The NIDA-funded Monitoring the Future
(MTF) survey shows that daily cigarette smok-
ing by teens has decreased almost 50 percent
over the past 5 years. Yet, measuring e-cigarette
usage for the first time in 2014, MTF found that
over 17 percent of 12th graders had used them
in the past month and many of these e-cigarette
users had no reported prior use of tobacco ciga-
rettes or smokeless tobacco. My plea is for an
appropriate, rational, scientific appraisal of likely
risks and benefits. Above all, we must do more
to dispel any youth perception that e-cigarettes
cause no harm - they do - while encouraging
adults to do everything they can to stop using
tobacco products.”
Discussant and chief science adviser to the
Prime Minister of New Zealand, Sir Peter Gluck-
man commented: “What is clear is that unless
we obtain robust scientific evidence both as
to short and long-term effects, we will remain
confused as to whether e-cigarettes can be a
positive or negative contribution to public health
and whether their use can be regulated in such
a way as to promote positive rather than nega-
tive outcomes. We need to keep gathering evi-
dence while being prudent from normative ar-
guments as to what to do with this technology.
The realpolitik of policy formation in emotionally
charged areas where there is strong advocacy
for different positions from differing perspectives
and interests is complex. There are some inher-
ently very difficult trade-offs in the debate from
what we currently know. What would be unfortu-
nate is policy based on unscientific positioning
as a result of strong advocacy and selective use
of evidence and a failure to continue research.
This can only lead to ongoing confusion in poli-
cy formation and regulation”.
Speaker and chief medical officer and di-
rector of compliance at Nicovations Ltd, a sub-
sidiary of British American Tobacco, Dr. Kevin
Bridgman added: “There is growing consensus
among public health professionals that e-ciga-
rettes are significantly less risky than conven-
tional cigarettes. However, we believe that, in
order to realise their full potential, e-cigarettes
should be regulated to ensure appropriate qual-
ity and safety standards, whilst also allowing
sufficiently wide retail availability, appropriate
lifestyle positioning and flexibility for the rapid
introduction of product innovation. This would
provide greater confidence without stifling inno-
vation, while enabling these products to com-
pete effectively with cigarettes.”
Discussant and chair of evidence-based toxi-
cology at Johns Hopkins University, Dr. Thomas
Hartung, felt the whole question of e-cigarettes
comes down to new testing standards: “This is
a tremendous public health opportunity, which
we can easily block by applying traditional tox-
icity testing. If you insist on this, you are es-
sentially killing off the sector. Flavours added to
some e-cigarette brands such as pop-corn or
bubble-gum or even gin & tonic are a big issue,
and one wonders why they are there. What is
safe in food is not safe if inhaled. We need data
fast, but we must re-think how to go about it, as
MARCH 2015 EXPERT OPINION 51
traditional toxicology is not fit for this purpose.
To do so, we must find new ways to combine
the knowledge and vested interests of an in-
dustry which is no longer old-school and old-
science tobacco, but highly modern and on a
par with pharma, with the opportunities of new
approaches coming from academia and regu-
latory science. To get there, we have to resist
the reflex of discrediting each-others respective
scientists. Time will tell if we are able to put the
smoker’s health first.”
Panel moderator and president of the Eu-
ropean Group on Ethics in Science and New
Technologies (EGE), reporting to European
Commission President, Jean-Claude Juncker
and to the European Parliament, Professor
Julian Kinderlerer, summed up by advocating
for great understanding and compassion for
the addicted person: “Society both professes
intolerance for the use of ‘drugs’ and provides
the social settings to enable and make legiti-
mate their use. We talk of the rights and re-
sponsibilities of citizens and of how important
the individual is in society, but the inconsisten-
cies in treatment and punishments for various
lifestyle choices are manifest. I wonder are we
really individuals anymore. Autonomy arises
from the concept of dignity as the capacity of
a rational individual to make informed, unco-
erced decisions. As science walks a danger-
ous line between persuasion and informing,
we must be mindful of society stepping in and
requiring individuals to accept norms regard-
less of their own beliefs. In the case of ciga-
rettes and e-cigarettes, history will judge us
harshly as to how we answer this billion per-
son question. It may also look back in anger at
policy-making amounting to institutionalised
manslaughter.”
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