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October 2012

Disaster surveillance system wins award

Health policies need to foster right environment

FORUM

Home factors impact on kids’ asthma med compliance

CONFERENCE

PHILIPPINE FOCUS

AFTER HOURS

Singapore’s Gardens by the Bay

ESC rolls out new practice guidelines

Please visit www.isrd.org for further details

Nearly 100 Academic Speakers,15 Sessions and 6 Special Topics

ISRD 2012The very first joint scientific sessionswith the American Thoracic Society

English Sessions Highlights：

• Mechanical Ventilation

• Sleep Apnea

• Update Biomarkers and Therapeutic Strategies in Airway Diseases

• State-of-the-art Ventilation Strategy

• Highlight on COPD Management

• ALI Forum - Mechanism and New Drug Target

• Plenary Session - Message from ATS

• Infection and Immunity

• Translational Respiratory Medicine

Congress Secretariat Office：

UBM Medica ShanghaiE-mail: [email protected]

Chinese Alliance Against Lung Cancer(CAALC)

Shanghai Respiratory Research Institute

American Thoracic Society (ATS)

Prof. Monica Kraft

President of AmericanThoracic Society

Professor of Medicine,Vice Chair of Researchfor Department ofMedicine and Directorof the Duke Asthma,Allergy and AirwayCenter at DukeUniversity MedicalCentre

Prof. Chunxue Bai

President of the 8thISRD & ATS in ChinaForum 2012

Professor of Medicineand Chairman ofDepartment ofPulmonary Medicine,Zhongshan Hospital,Fudan University

Dr. Asrar Malik

Distinguished Professorand Head of theDepartment ofPharmacology,University of IllinoisCollege of Medicine

Schweppe FamillyDistinguished Professorof Pharmacology

Hosted by:

Supported by:

Keynote Speakers:

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ISRD_290x406_V2_PRINT.pdf 1 12/09/2012 6:11 PM

3 October 2012

Elvira Manzano

Five new practice guidelines from the European Society of Cardiology (ESC) recommend new agents, devices and

therapeutic options for managing valvular disease, ST segment elevation myocardial infarction (STEMI), heart failure (HF), atrial fibrillation (AF) and cardiovascular disease (CVD) prevention. A consensus statement was also issued on the latest universal defini-tion of myocardial infarction (MI).

For valvular disease, the importance of a collaborative approach between cardiologists and cardiac surgeons working as a “heart team” has been emphasized. For the first time, transaortic valve implantation (TAVI) is recommended in patients with severe symp-tomatic aortic stenosis (AS) who are unsuit-able for surgery, but only in hospitals with cardiac surgery on site. TAVI should not be performed in patients at intermediate risk for surgery.

Mitral valve repair is the preferred tech-nique in mitral regurgitation, when the repair is considered durable. Mitraclip device may be considered in high-risk or inoperable pa-tients resistant to optimal medical therapy.

In HF, the key changes from the 2008 ESC guidelines include a new indication for miner-alocorticoid antagonist (MRA) eplenerone in patients with systolic HF and mild symptoms, broadening the indication to essentially all HF-REF patients remaining symptomatic despite treatment with a beta-blocker and ACE inhib-itor or ARB. Ivabradine is now recommended to be added to an ACE inhibitor, beta-blocker and MRA for HF-REF patients in sinus rhythm with a persistently high heart rate (>70 bpm).

The use of cardiac resynchronization thera-py (CRT) has been expanded to patients with mild symptoms. Those with a left ventricu-lar ejection fraction (LVEF) of 35 percent or lower, sinus rhythm, and left bundle-branch block QRS morphology, however, benefit the most from the device.

The guidelines also recognize the increas-ing importance of cardiac MRI and include mid-regional proBNP as a ‘rule-out’ blood test in patients with acute HF.

Reperfusion therapy is recommended for all STEMI patients within 12 hours of first symptoms, and beyond the 12-hour window period if there is persistent pain and ECG changes. Clopidogrel and aspirin are recom-mended for fibrinolysis. Dual antiplatelet therapy is indicated for up to 12 months in those having primary PCI, a minimum of 1 month for those receiving a bare metal stent and 6 months for a drug-eluting stent.

For stroke prevention, the use of CHA2DS2-VASc score instead of the CHADS2 score is now recommended for identifying at-risk pa-tients, and new oral anticoagulants such as

ESC rolls out new practice guidelines

The new guidelines include a range of new options for managing heart conditions.

4 October 2012

dabigatran, rivaroxaban or apixaban are now considered preferable to vitamin K antago-nists (Class IIA). Dual antiplatelet therapy with aspirin and clopidogrel, or aspirin only, may be considered in patients who refuse anticoagulation.

Percutaneous closure of the left atrial appendage (LAA) may be considered in those with thromboembolic risk who cannot be managed with oral anticoagulants in the long term. Vernakalant has been introduced as a new antiarrhythmic agent for rapid cardioversion of recent onset AF, with few exceptions. The guidelines also highlight the revised use of dronedarone for paroxysmal or persistent AF. However, it is contraindicated in permanent AF and heart failure.

Catheter ablation is advised for patients with symptomatic paroxysmal AF who have failed antiarrhythmic medications (Class IA).

The guidelines on CVD prevention focus on CVD risk, why prevention is needed, and who should benefit from it. CV risks are classified as very high, high, moderate and low. Strong recommendations are given on diet, smoking, hypolipidemic medications, exercise and other behavioral risk factors.

The ESC also released the latest defini-tion for five types of MI and their clinical implications. The consensus document now recognizes that small amounts of myocar-dial injury or necrosis can be detected by biochemical markers and imaging.

Tai chi can benefit patients with COPD

Elvira Manzano

A modified tai chi program may im-prove the exercise capacity and qual-ity of life of patients with chronic

obstructive pulmonary disease (COPD), new research has shown.

In a randomized controlled trial, patients assigned to tai chi were, on average, able to walk 55 meters (95% CI 31 to 80) farther and 384 seconds (95% CI 186 to 510) longer at 12 weeks compared with a control group. [Eur Respir J 2012; DOI:10.1183/09031936.00036912]

“An important finding from our study was the significant improvement in bal-ance and muscle strength following Sun-style tai chi training, which has the poten-tial to reduce the risk of falls in people with COPD,” said one of the study authors Dr. Tai chi improved muscle strength and balance in study patients.

5 October 2012

Jennifer Alison, from the University of Sydney, Australia.

Lower limb muscle weakness and impaired gait and balance are common in people with COPD and are major risk factors for falls.

In the study, patients were randomized to a 12-week tai chi program, consisting of a 2-hour session each week, or standard COPD treatment without exercise. The majority of the patients were males. Average age was 73, with co-morbidities that included osteoar-thritis, hypertension, dyslipidemia and coro-nary heart disease. On days when patients were not on sessions, they practiced tai chi at home for 30 minutes.

Compared with the control group, patients on tai chi exercise performed 75 percent bet-ter in the walking test and had a significantly higher score in the Chronic Respiratory Dis-ease Questionnaire, which indicates better quality of life.

Additionally, tai chi was associated with moderate intensity exercise as demonstrated by a 53-percent reserve in oxygen consump-

tion. Significant improvements in balance, strength and performance were also observed in the tai chi group. The effects of tai chi were comparable to what can be achieved during conventional pulmonary rehabilitation.

“This is good news for people with COPD because it gives them more fitness choices,” said lead study author Ms. Regina Wai Man Leung of Concord Repatriation General Hos-pital and the University of Sydney, Austra-lia. “With increasing numbers of people be-ing diagnosed with COPD, it is important to provide different options for exercise that can be tailored to suit each individual,” added Leung, a cardiorespiratory physiotherapist.

The authors said the study provides com-pelling evidence that tai chi may be an effec-tive alternative training modality for people with COPD who have limited or no access to pulmonary rehabilitation. The high degree of adherence with both formal and at-home training and practice suggests that the pro-gram is feasible for COPD patients, even for those with comorbidities, they concluded.

6 October 2012 Forum

Health is intrinsically related to wealth. The Prospective Urban Ru-ral Epidemiological (PURE) study,

a survey of 153,996 adults from 628 urban and rural communities in 17 countries, has highlighted the discrepancies in lifestyle and diet between high-income and low-in-come nations.

The average fruit and vegetable con-sumption per day should be 500 grams or 5 servings, but surprisingly, our analysis of PURE showed that one-third of the coun-tries of the world are not consuming ad-equate amount. The consumption of fruits and vegetables increased among nations with a higher gross domestic product (GDP) and wealth index, but this was offset by an increase in the amount of energy obtained from total and saturated fats, as well as from protein. Energy from total fat, saturated fats and protein increased almost linearly with increasing incomes. Carbohydrate intake, on the other hand, made up approximately 65 percent of energy from diets in poor na-tions – this is because carbohydrates are a cheap source of energy – with the percent-age declining in wealthier nations.

Regarding smoking, the decision to smoke in women depends not only on GDP or wealth but also on cultural factors, includ-ing religion. In men, there is a clear inverse

Health policies need to foster right environmentExcerpted from a presentation by Professor Salim Yusuf, lead researcher of the PURE study and director of the Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada, during the 2012 European Society of Cardiology Congress held recently in Munich, Germany.

relationship between GDP and wealth and smoking status. Approximately 45 percent of men in the poorest countries smoke com-pared with 20 percent of men in the richest countries. Men started smoking at approxi-mately the same age and frequency in all countries, but the rate of quitting is mark-edly higher in higher-income countries. This is important because the focus of smoking should be on quitting. It’s the people who are alive today and who are smoking today who will die in the next 40 years from to-bacco. If you can get people to quit, then the children will not start. This is what we call ‘epidemiological transition,’ and this is what determines risk factors.

In terms of physical activity, the amount of recreational physical activity increased with increasing GDP and wealth, but

Recreational exercise alone won’t solve the obesity epidemic problem.

7 October 2012 Forumthis increase was offset by a reduction in the amount of obligatory physical activ-ity that is transport-related, job related and household-related activity required for physical labor. Overall, the net result was a reduction of approximately 2,000 [metabolic equivalent task] METS/minute/week, or 2.7 hours of brisk walking every day, among countries with higher incomes.

There is no way – unless you are a mar-athon runner – that we are going to over-come the decrease in activity due to the changing environment. The obesity epi-

demic really requires a change in environ-ment. We can yell at people and say, ‘exer-cise’ 30 minutes a day. But it is not going to be enough. It’s about one-fourth of the difference of lost physical activity which means that in the future, we will all be on treadmills.

While there are creative solutions, the key point is to understand that recreational exercise won’t solve the problem and the entire environment needs to be redesigned. That’s where policy comes in. We really need to create the right environment.

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9 Philippine FocusOctober 2012

Dr. Yves St. James Aquino

A meta-analysis by Dr. Rico Paolo Tee et al. comparing standard dose versus high dose anthracyclines as part of the “3+7”

induction chemotherapy for acute myeloid leu-kemia (AML) in adults showed dose intensifica-tion have benefits for AML patients. Previous efforts to improve outcomes in AML treatment have included dose adjustments of current standard chemotherapy protocols, with studies demonstrating beneficial effects with dose intensification of daunorubicin or idarubi-cin. The “3+7” used for induction chemotherapy typically involves a three-day anthracycline and seven-day cytarabine treatment. Based on three relevant studies, the meta-analysis showed that odds of complete remission and event free survival almost doubled with the higher dose. The odds of overall survival were 1.6 times higher in high-dose anthracycline group compared to the standard dose. There were no significant difference between the two groups in terms of risks of cardiomyopathy and infectious complications. Tee, lead author from the Philippine Gen-eral Hospital-Department of Internal Medicine, explained that this is relevant not only to Filipino patients, but to all leukemics in general. “Before, we were quite afraid to increase the doses of our drugs due to its side effects. To say, we might be killing our patients rather than the

cancer. When we tried to unite the data from the different studies, we found that in patients who have a structurally sound heart, we can try to increase our chances of being cancer-free by in-creasing our drug doses without harming our patients,” added Tee. Current regimens that use standard dose are done because of fear that dose intensification will increase unwanted effects without increasing the benefits. “Chemotherapeutic drugs are poisons – they poison the cancer and at the same time poison healthy cells. Especially with the drug we inves-tigated here, daunorubicin (and the other anthra-cyclines), the most feared side effect is the devel-opment of cardiomyopathy, eventually leading to heart failure,” said Tee. Other side effects include increased susceptibility to infections, nausea, vomiting, he added. The study authors recommended more stud-ies to investigate the benefits or side effects of incorporating this dose adjustment in standard regimens. They also recommended investigating treatment adjustments in consolidation therapy, which is done after initial or induction chemo-therapy. “Complete success in the treatment of AML lies not only in the induction phase, but also in consolidation and maintenance. Given that we have higher successes with high dose anthracyclines for induction, we now need to find what our wisest next step need to be,” concluded Tee.

Philippine Society of Hematology and Blood Transfusion 42nd Annual Convention; 1-5 September; Crowne Plaza Manila Galleria Hotel, Ortigas

Chemotherapy dose intensification shows benefits in AML

CONFERENCE COVERAGE



Stem cell remains the only curative therapy for JMMLGabriel Angelo Sembrano

Allogeneic hematopoietic stem cell transplantation (HSCT) is still the only treatment that offers proven

curative therapy for juvenile myelomono-cytic leukemia (JMML), according to Dr. Ann Veronique Eguaras, pediatric hematologist-oncologist with the San Pablo Colleges Medi-cal Center in Laguna. For patients not able to undergo hematopoietic stem cell transplant, the probability of reaching 10 years old is less than 10 percent.

A study by F. Locatelli et al., in 1993 to 2002, involving 100 children, with 67 males and 33 females, from 29 centers in seven countries, concluded that “HSCT, after a preparative regimen consisting of busulfan, cyclophos-phamide, and melphalan, may cure approxi-mately 50 percent of patients with JMML.” The study revealed that results obtained from unrelated-donors (UD) are comparable to those obtained employing a human leuko-cyte antigen (HLA)-compatible related do-nor. Spleen size, may it be splenectomized or not, did not appear to be a factor or to pose an impact on the post-transplantation outcome [Blood. 2005 Jan 1;105(1):410-9].

In addition, the study showed that the karyotype, may it be normal or abnormal, does not have an impact on the chance of overall survival after HSCT. It was also ob-

served that there is no significant difference in the event free survival (EFS) level among those children given with acute myelogenous leukemia (AML)-type of chemotherapy com-pared to those who were given with less in-tensive treatment. However, recurrence of the disease remains the major cause of treatment failure with a median time of 4 to 6 months from HSCT. Patients who are less than 4 years old have a predictive variable for relapse.

Eguaras pointed out that there is no proof showing that chemotherapy by itself could bring out long-term effects against JMML. However, maintenance type or low-dose chemotherapy may be considered in certain cases. She mentioned that based on the current guidelines for therapy of JMML by the European Working Group of Myelodys-plastic Syndromes (EWOG-MDS), 50mg/m2/day of oral 6-mercaptopurine produce results against pulmonary problems, very high white-blood cells and prominent organomegaly. She added that when this is

CONFERENCE COVERAGE

HSCT, after a preparative regimen consisting of

busulfan, cyclophosphamide, and melphalan, may cure

approximately 50 percent of patients with JMML

‘‘


combined with 100mg/m2 SD of cis-retinoic acid, this inhibits spontaneous proliferation of JMML myeloid progenitors; however, this claim remains controversial.

For severe or progressive cases, low dose of 40mg/m2/day for 5 consecutive days of IV cytarabine or high dose of 2g/m2/day for 5 consecutive days cytarabine combined with 30mg/m2/day for 5 consecutive days of fluda-rabine is recommended. It is advisable to observe for rabid rebound effect that may lead to pulmonary infiltrates that could be fatal

In a study by C. Niemeyer et al., which aimed to define the clinical and hematologic characteristics of the disease, almost all cases (97 percent) showed splenomegaly and hepa-tomegaly while lymphadenopathy was mani-fested in 76 percent of the patients. Among other signs and symptoms were pallor at 64 percent, fever at 54 percent, bleeding at 45 per-cent, infection at 46 percent and cough at 40 percent. Small portions of malaise, skin rash, café au lait spots and xanthoma were also ob-served. [Blood May 15, 1997 vol. 89 no. 10]

Eguaras pointed out that under the clas-sification of myeloid neoplasms according to the 2008 World Health Organization Scheme, JMML is categorized under myelo dysplas-tic/myeloproliferative neoplasms (MDS/MPN)

together with chronic myelomonocytic leu-kemia (CMML) and atypical chronic myeloid leukemia, BCR-AML-negative (aCML). The distinct feature that differentiates it from CMML and aCML is that it lacks Philadelphia chromosome (t 9; 22) or breakpoint cluster re-gion - breakpoint cluster region (BCR - ABL) fusion gene.

According to Eguaras, JMML is a “rare hematopoietic malignancy of early child-hood, representing 2 percent to 3 percent of all pediatric leukemias.” This disease of the blood is characterized by clonal hyperpro-liferation of monocytes and granulocytes without arrest in differentiation. Its actual incidence remains unknown but accord-ing to the European Working Group for Myelodysplastic Syndromes there are about 1.2 victims in every million children per year and the median age of diagnosis is at 1.8 years. So far, the recorded cases of male patients outnumber the female patients at 2:1.

Although firm molecular diagnosis can now be made in 90 percent of cases, clinical fac-tors such as older age, low platelet count and higher HbF correlate with poor outcome and HSCT remains to be the only curative therapy, concluded Eguaras.


Better risk stratification prior to HSCT improves ALL outcomeDr. Yves St. James Aquino

Studies have shown that better risk strat-ification prior to initiation of hemato-poietic stem cell transplant (HSCT) in

children with acute lymphoblastic leukemia (ALL) improves overall outcome, said Prof. Dr. Rupert Handgretinger, pediatric oncolo-gist with the Children’s University Hospital, University of Tübingen, Germany.

In a study that evaluated the effectiveness of various treatments for ALL in the absence of cranial irradiation, results showed that the 5-year event-free and overall survival prob-abilities for all the 498 patients were 85.6 per-cent (95 percent CI, 79.9-91.3) and 93.5 percent (95 percent CI, 89.8-97.2), respectively. Alloge-neic hematopoietic stem-cell transplantation (allo-HSCT) was given as option for patients considered to have high-risk leukemia, with median time to transplantation after remis-sion induction at 4.1 months [N Engl J Med 2009; 360:2730-2741].

Results from the Malaysia-Singapore study on ALL using minimal residual disease (MRD)-guided stratification and identification of poor responders concluded that three-drug (dexamethasone, vincris-tine and asparaginase) remission-induction therapy combined with MRD-guided risk

stratification was an effective strategy for childhood ALL [J Clin Oncol 2012; 19: 2384].

In this study, 556 patients were stratified as high-risk ALL, standard-risk or interme-diate-risk ALL. High-risk ALL patients were those with MRD>1x10-3 at week 12 and/or poor prednisolone response, BCR-ABL1/MLL rearrangement or hypodiploid, infant CD10-negative ALL, or induction failure. Standard-risk ALL was defined by MRD<x10-4 at weeks 5 and 12 with no extramedullary involvement or high-risk features. The rest were interme-diate-risk ALL. Cumulative outcome showed that the 6-year event-free survival was 80.6%, while the overall survival was 88.4%. Based on risk groups, however, overall survival out-come at 6 years for standard risk was 95.4%, intermediate 92.1%, and high risk 67.7%.

In the absence of MRD, selective addition of Day 15 or early bone marrow response to stratification criteria may significantly improve risk-adapted treatment delivery [haematol 2012 97;7:1048-1056]. High risk was defined as prednisone-poor response, and/or no complete remission on Day 33, and/or evidence of t(9;22) or BCR/ABL, and/or evidence of t(4;11) or MLL/AF4. Median risk was defined as initial WBC>20x109/L, and/or age at diagnosis of <1 or >6 years and/or T-cell ALL. Standard risk was defined as initial WBC<20x109/L, and age at diagnosis ≥1 and <6 years, and no T-cell ALL.

The issue in pursuing HSCT in second remission or await future relapse has always been controversial. A study done at the University of Minnesota involved 15 patients who had an early relapse, while 26 had an

The issue in pursuing HSCT in second remission or await

future relapse has always been controversial

‘‘


initial late relapse prior to allo-HSCT. At the time of allo-HSCT, 30 patients (73 per-cent) were in second remission, while 11 (27 percent) were in third. Results showed that there was inferior disease-free survival in patients who had late-relapse transplanted during third remission compared with those transplanted in second remission (30 percent versus 75 percent, p=0.04), which suggest that allo-HSCT should be pursued in children

after a first marrow relapse instead of wait-ing for future recurrence [Bone Marrow Trans-plant. 2011 Jul;46(7):950-5].

According Handgretinger, stem cell transplantation can be done even in late relapse because the HSCT overall out-comes have improved. However, if there ex-ists a high transplant-related mortality, the patient may be better off with chemotherapy alone.

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Pediatric regimen recommended for adolescents and young adults with ALL


Dr. James Salisi

P ediatric regimen should be used for treatment in acute lymphoblastic leu-kemia (ALL) in adolescents and young

adults, related Dr. Patricia Alcasabas, consul-tant and assistant professor with the National University Hospital in Singapore. Studies comparing the outcomes for treatment regi-mens demonstrated that ALL patients 15 to 21 years old show better outcomes for those who used the pediatric regimen than adult regimen.

Age is a prognostic factor in ALL and this is why in the treatment of this con-dition, adolescents and young adults are unique populations that may not categori-cally belong to either pediatric or adult treatment regimen. Their uniqueness is at-tributed to several factors including genetic abnormalities, compliance and treatment approach.

The ten-year survival rate for adolescent patients (15 to 21 years old) is 60 percent, while for young adults (20 to 39 years old) is 43 percent. The highest survival rate is for 1 to 9 years old, which is 81 percent. Cytogenet-ic differences may account for the differences in survival between these age groups. For in-stance, Alcasabas cited that there is a higher proportion of Philadelphia chromosome in adolescents and young adults than younger children.

Sensitivity to chemotherapeutic drugs is also a factor in the outcomes of ALL patients, with early treatment response playing a cru-cial role in the course of the therapy. Studies showed that as children get older, their re-sponse to chemotherapy tends to get poorer and toxicities tend to be higher.

“It is indeed a unique subset, adolescents and young adults with ALL. So, which treat-ment regimen are we going to use? They are not children and they are not adults, so we just look at data,” Alcasabas said. She cited studies in other countries which compared event-free survival of adolescent patients who underwent pediatric versus adult treatment protocols. Overall, experience in the USA, the Netherlands, France, the UK, and Sweden showed that pediatric regimen resulted in higher rates of five-year event-free survival.

A closer look at the treatment regimen used in the Netherlands showed that the difference of pediatric regimen from adult regimen: use of high-dose methotrexate can reduce the incidence of systemic relapse, there is a re-intensification, a maintenance phase, no role for autologous bone marrow transplant, and shorter rest in between chemotherapy.

In countries with limited resources, treat-ments should be ensured in such a way that supportive care issues are addressed and toxic deaths are avoided.

CONFERENCE COVERAGE


Developing countries should focus on screening for thalassemia, says expert


Dr. James Salisi

S outheast Asia has the highest preva-lence of thalassemia trait carrier in the world and thereby estimated to

have the highest prevalence of newborns with thalassemia syndromes. Every year it is estimated that 1,200 to 7,000 babies in Burma and more than 12,000 in Cambodia and Indonesia are born with beta thalassemia.

The cost of treatment annually of severe thalassemia can add up to 5 percent of the annual health budget in Sri Lanka and could go as high as 150,000 Euros in Thailand for a 30-year lifespan. The high economic and social costs of having thalassemia syndromes raise the importance of screening for it in the population to improve public health.

“Screening for thalassemia in develop-ing countries comes with several advan-tages,” said Dr. Vip Viprakasit from Siriraj- Thalassemia Center in Thailand. Preven-tion, under which screening falls, is cheaper and better than treatment for thalassemia in the population. For example, the cost of preventing four cases of beta thalassemia would be roughly USD1,300 while the cost of treatment for 30 years of these cases would run up to more than USD700,000.

In designing a prevention and control program, Viprakasit enumerated sever-al steps which included: identification of

disease carrier in a population; educating disease carriers on thalassemia; dissuasion of marriage between carriers; alternative options on getting offspring in couples at risk, such as adoption, egg donation and no offspring; pre-implantation genetic diagnosis; and prenatal diagnosis and counseling.

Specifying the population to be screened is one of the first questions that should be answered in implementing a prevention program for thalassemia. Newborns, school children, pre-marital couples, and unborn children can be screened but the selection of a particular population depends on the capacity of the health sector and the acceptance of the public. In Thailand, school children were the first population to be screened.

The experience of Thailand in screen-ing for thalassemia sets a good example for other developing countries in designing their own screening programs. The country has a high prevalence of thalassemia and hemoglobinopathies. In order to address this, a national screening policy was created in 1994 under the Ministry of Public Health and dubbed as the National Programme for the Prevention and Control of Severe Thalassemia Syndromes. They screened for thalassemia carriers in pregnancy using simple and cheap methods such as

CONFERENCE COVERAGE


osmotic fragility test for thalassemia traits and dichlorophenolindophenol (DCIP) precipita-tion test for hemoglobinopathies.

Confirmatory tests include high pressure liquid chromatography, hemoglobin electro-phoresis and DNA study for alpha thalas-semia. Patients confirmed to be thalassemia carriers are advised about their condition. Prenatal diagnosis for couples at risk is also available. Fetal cells in maternal circulation and fetal DNA from maternal plasma are used for pre-implantation diagnosis of thal-assemia.

For newborns, isoelectric focusing can diagnose hemoglobinopathies and thalas-

semia. In Thailand its sensitivity and spec-ificity are pegged at 100 percent. In the Philippines, steps are being taken to include thalassemia in the National Newborn Screen-ing Program.

Viprakasit emphasized that once thal-assemia screening is started, there should be continued support by the public edu-cation and regulatory structures, empow-erment of individuals by medical profes-sionals to make informed decisions, and assurance that people are protected against discrimination. He added that education is critical in addressing discrimination against thalassemia carriers.

New treatments increase TTP survivalGabriel Angelo A. Sembrano

I n the advent of therapeutic plasma ex-change (TPE) treatment for thrombotic thrombocytopenic purpura (TTP), a lot

of patients have improved their chances for survival, according to Dr. Ivy Mae Escasa, he-matologist with the Manila Adventist Medi-cal Center. She added that this effectiveness is due to TPE’s capacity to remove circulating and unusually large von Willebrand factor platelet strings; that it also removes autoan-tibodies against ADAMTS13 and replenishes deficient ADAMTS13.

TPP is a hematologic condition that causes blood clots to form in small blood vessels around the body, and leads to a low platelet count. Symptoms include bleeding into the skin or mu-cus membranes, changes in consciousness, con-fusion, easy fatigue, fever, headache, heart rate over 100 beats per minute, pallor, purplish spots

on the skin, shortness of breath, speech changes, weakness and jaundice.

In diagnosing TTP in the past, Escasa noted that “physicians look for the classic pentad.” This classic pentad includes fever, microangiopathic hemolytic anemia, thrombo-cytopenia, neurologic abnormalities and renal abnormalities.

“Now, we only need microangiopathic hemolytic anemia, thrombocytopenia without another apparent etiology to clinically diagnose a patient and then to begin treatment,” Escasa explained. She also stated that the diagnosis of TTP is still based on the presenting clinical features. Measurements of a disintegrin and metalloproteinase with a thrombospondin

If left untreated, mortality due to TTP is very high and can even go up to 90 percent

‘‘


type 1 motif, member 13 (ADAMTS 13) activity are not required and may not be appropriate for the critical initial management decision to begin or not to begin TPE [Blood, 116;20:4060–4069, 2010].

However, she pointed out that based on several studies, there is a significantly great-er chance of relapse with severe ADAMTS13 deficiency during the acute stage of TTP. In fact, a study by Ferrari et al. in 2007 showed that for ADAMTS13 activity lesser than 5 percent, 38.5 percent relapsed; and for ADAMTS13 activity greater than 15 percent, only 5 percent relapsed [Blood, 109;7:2815–2822, 2007].

According to the 2012 guidelines on the diagnosis and management of TTP and oth-er microangiopathies, increased TPE and/or rituximab therapy are the agents of choice in relapsing disease. However, Escasa questions its use at presentation in an acute episode. She mentioned that based on a 2011 study by Scully et al., the use of weekly rituximab in conjunction with TPE and steroids was safe,

efficacious, and well tolerated [Blood. 2011 Aug 18;118(7):1746-53].

Results of a study on rituximab as pre-emptive treatment for TTP showed that rituximab is effective in maintaining a sus-tained remission in patients with ant-AD-AMTS13 antibodies in patients who did not respond to treatments to limit production of in-hibitors [Thromb Haemost. 2009 Feb;101(2):233-8]. Escasa added that according to these guide-lines, patients with a documented reduction of ADAMTS 13 activity to <5 percent, elective with rituximab can be considered. She con-cluded that “rituximab can be given at presen-tation, can be given during refractory disease,

during relapse and as a prophylaxis.” According to Escasa, if left untreated,

mortality due to TTP is very high and can even go up to 90 percent. “But in the 1980’s and up to the 1990’s, utilization of therapeutic plasma exchange improves the survival of these patients. Mortality rate went down to 10 to 20 percent with the use of plasma exchange.”

Adapted from George. Blood, 116;20:4060–4069, 2010

Evolution of treatments and outcomes for patients with TTPPeriod Treatment Survival (%)1925-1964 Corticosteroids, antiplatelet agents, splenectomy 101964-1982 Plasma infusion, beginning use of plasma exchange (PEX) 461982-2008 PEX, inconsistent use of adjuvant treatments 802008-2012 PEX, corticosteroids, beginning use of rituximab 90

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Conference Calender

October

12th Asian Oceanic Society of Paediatric Radiology (AOSPR) Congress and the 9th Joint Convention of CT-MRI and Ultrasound Societies of the Philippines October 4-6, 2012Venue: SMX Convention Center, Pasay CityInfo: Asian Oceanic Society of Paediatric RadiologyTelephone: (632) 373 8462Email: [email protected]: www.aospr.com

1st Annual Convention Philippine College of Geriatric MedicineOctober 8-9, 2012Venue: Century Park HotelInfo: Philippine College of Geriatric Medicine Telephone: (632) 394-3066Website: http://www.geriatricsphilippines.org/

21st Philippine College of Physicians Midyear ConventionOctober 11-13, 2012Venue: Mimosa Holiday Inn, Clark Field, PampangaInfo: Philippine College of PhysiciansTelephone: (632) 910 2250 Website: www.pcp.org.ph

12th Philippine Society of Pathologists Midyear ConventionOctober 25-26, 2012Venue: Davao Insular Waterfront Hotel, Davao CityInfo: Philippine Society of Pathologists Telephone: (632) 738-6814, (082) 301-7008 Fax: (082) 300-3098Email: [email protected], [email protected]: www.philippinepathology.org


Scientists present locally developed rapid test for DengueGabriel Angelo Sembrano

F ilipino scientists have recently devel-oped a rapid test kit for Dengue, as presented during a research forum

held at the National Institutes of Health at the University of the Philippines Manila last August 28, 2012. Dr. Raul Destura, director of Institute of Molecular Biology & Biotechnolo-gy-National Institutes of Health (IMBB-NIH) and Biotek-M project leader, and Ms. Regina Berba, infectious diseases specialist at the Philippine General Hospital-Hospital Infec-tion Control Unit, presented the newly devel-oped Biotek M Dengue Assay.

Destura and Berba explained that this re-cent development could be of great help es-pecially to those working in the field where primary health settings have very limited lab-oratory capabilities. The use of clinical find-ings as the only basis for diagnosing dengue is quite unreliable. Biotek M Dengue Assay could fill this gap since it can accurately de-tect the presence of dengue especially if done promptly during the progression of the fe-brile illness.

The new assay would result in lesser ex-penses on the part of the patients since they will no longer need to visit hospitals; and in better decisions on the part of the medical pro-fessionals since they could already confirm or rule out dengue at the soonest possible time. Moreover, this technology could eventually help in the reduction of morbidity and mortal-ity brought about by this infection.

According to the proponents, the field test-ing involved a sample of 117 patients who

consulted for fever. Among the 117 patients, 59 percent (95 percent CI; 49.5%, 67.9%) tested positive for dengue by way of reverse transcription-polymerase chain reaction (RT-PCR). The dengue serotypes identified were predominantly DENV1 and DENV3. Re-searchers emphasized that based on the find-ings from the blood samples taken from Days 1 to 7 after the patients’ admission, the Biotek-M Dengue Assay has an overall sensitivity of 0.753 (95 percent CI; 0.632, 0.846) and specific-ity of 0.750 (95 percent CI; 0.601, 0.858) with a likelihood ratio for a positive test of 3.014 (95 percent CI; 1.813, 5.011). They also noted that its accuracy is better when done at the earliest possible time.

The sensitivity of Biotek M was noted to be at 0.812 (95 percent CI; 0.669, 0.906) if the test was done on Days 1 to 5; 0.800 (95 percent CI; 0.625, 0.909) if the test was done on Days 1 to 4; and 0.923 (95 percent CI; 0.621, 0.996) when the test was done on Days 1 to 3. Furthermore, the Biotek-M Dengue Assay was able to detect dengue in 12 samples which were negative

The Biotek-M Dengue Assay was able to detect dengue

in 12 samples which were negative on Dengue RT-PCR

‘‘


on Dengue RT-PCR. This greater yield is attributed to the lower threshold of gene detection by the Biotek-M Dengue Assay.

According to the World Health Or-ganization, dengue is the most com-mon mosquito-borne viral disease of hu-mans, and considered as a major global

public health concern. In the Philippines, the Department of Health has recorded 32,193 dengue cases nationwide with 195 deaths from January to June this year. This number has surpassed the 30,989 cases recorded during the same period last year.

Leptospirosis disease burden remains high in NCRDr. James Salisi

A total of 2,976 disability adjusted life years (DALYs) were lost in the National Capital Region due to lep-

tospirosis, a study conducted by Maridel Borja, PhD from the University of the Philippines Manila revealed.

Developed by the Global Burden of Disease study of the World Health Organization and the World Bank, DALY is an objective indicator of health status and can be used as measure for determination of health priorities. The study was conducted to determine the burden of leptospirosis in terms of DALYs and the total cost of managing complicated cases.

Premature deaths accounted for 92 percent of the DALYs lost, while only 8 percent due to years living with disability. This puts leptospirosis at par with dengue, measles, Japanese encephalitis, hepatitis B, malaria and schistosomiasis in DALYs lost.

The economic burden of leptospirosis is quite high with an average expenditure per case at PhP15,487.44. This amount is almost twice the monthly minimum wage in Metro Manila, which is estimated to be PhP9,372.

The items that contribute to this cost include drugs and medicines administered to the patients at PhP2,525.25, PhP1,376.24 for intravenous fluids, PhP4,477.00 for hospi-tal room cost and PhP3,505 for the median income losses of the patients and their watchers.

With this in mind, leptospirosis should be given as much importance as the other diseases like dengue and malaria.

Leptospirosis prevention and con-trol in highly urbanized and flood prone cities should be strengthened to decrease the burden of disease and its economic impact especially on poorer populations who are more at risk to acquire this disease.

The improvement of environmental sanitation plays an important role in preventing the spread of leptospiro-sis. The study recommended improving environmental sanitation to prevent fa-vorable conditions for the proliferation of rodents within and outside homes. Mem-bers of the community are urged to help prevent further flooding through proper garbage disposal. Environmental sanita-tion should also include regular clean-up of stagnant creeks that pass through the


National Capital Region.Early detection and improving the health

information system are likewise important in reducing deaths due to leptospirosis be-cause they direct and prompt proper treat-ment and thus lower the risk of dying. A rapid diagnostic test for antigen would greatly help

in detecting the disease early and should be the focus of research.

Finally, the study recommends placing equal importance to leptospirosis, along with other infectious diseases, in terms of prevention and control as well as research initiatives.

Disaster surveillance system wins award for health innovationDr. Yves St. James Aquino

G aling Likha Kalusugan (GLK) award was recently conferred on Surveil-lance in Post Extreme Emergencies

and Disasters (SPEED), calling it one of “the best examples of the highest level of innova-tion in the country’s health marketplace,” ac-cording to a press release by the World Health Organization-Western Pacific Region.

Created in 2010 by the World Health Orga-nization, in collaboration with the Department of Health-Health Emergency Management Staff, USAID, AUSAID and the government of Finland, SPEED is an early warning dis-ease surveillance system done after disasters, with the aim of determining early and poten-tial disease outbreaks and disease trends. The award of merit acknowledges the pioneering web-based system as the world’s first early warning disease surveillance.

The GLK award is a joint initiative of the Philippine Institute for Development Studies (PIDS) and the Center for Health Market Inno-vations (CHMI), an international organization funded by the Rockefeller Foundation devot-ed to identifying and replicating innovative health programs around the world.

The award recognizes SPEED’s signifi-cant contribution during and after disasters, especially with its relevant and up-to-date reporting of health conditions and trends in evacuation centers and hospitals to prevent further health disasters or disease outbreaks.

SPEED was conceptualized after three major disasters, which included Ondoy, Pepeng and Santi, caused wide-scale flood-ing in the country back in 2009. These

‘‘ Health managers need to act quickly based on reliable data to prevent a secondary

disaster from happening


disasters caused leptospirosis outbreak in many parts of the country, which prompted an investigation by the Global Outbreak Alert Response Network that eventually reiterated the need for improved information system during and after disasters.

“What happened in 2009 was a wakeup call for us. It caught many health workers off-guard, because they too were victims of the flood,” said Dr. Carmencita Banatin, Di-rector of the DOH-HEMS. She added that the department decided to improve monitoring health conditions in post-disaster scenarios and asked the WHO’s help in developing a surveillance system through texting.

“Health managers need to act quickly based on reliable data to prevent a second-ary disaster from happening,” said Dr. Soe

Nyunt-U, WHO Representative in the Philip-pines.

The surveillance system manages the impact of calamities through the use of web-based software which can receive data via text messaging, as well as enable validation of data online and automatic generation of necessary charts and graphs, spread sheets, maps and narrative reports. The system shortens the time for transfer of sur-veillance data from barangay or evacuation center level to all levels of the health system, reaching up to the national level. The system has a built-in capacity to alert officials if certain diseases exceed the epidemic threshold. In addition, the surveillance system also involves nationwide trainings for local government officials .


Expansion, collaboration for a better heart society

The Medical Tribune’s Dr. Yves Saint James Aquino talks to presidents of specialty societies to discuss their roles in promoting their respective fields

Dr. Saturnino JavierPresidentPhilippine Heart Association

NOTES ON LEADERSHIP

Medical Tribune: What is the importance of being the president of PHA?

Dr. Saturnino Javier: “I’ve always said this, the presidency of Philippine Heart Association is just the culmination of the entire seven to eight years of your stay in the PHA board. In a way, the seven to eight years is your preparation for your presidency. Even from the directors’ level, you start laying the groundwork for your presidency. If you maintain that you will only start doing things ‘pag presidente ka na, you’re late. Slowly, every step of the way, you try to lay the groundwork for your term as president. Sa term mo na lang as president, that’s the time you really zero in on the key areas that you intend to work on for your term.”

MT: What are some of the key areas you want to focus on?

SJ: “PHA has nine chapters strategically located in the different islands. We’d like to empower our chapters more by making them feel as very integral part of the central Manila-based PHA. Because one of the comments that we heard before is that the central society is too detached from the chapters. They’re like peripheral units without any direct synchronized and harmonized work with the central society. I’d like to work on that; make the chapters feel that we work along the same lines, with parallel activities.

“We’re a sixty-year-old organization, so we’d also like to expand the membership. I’d like to open PHA to non-medical members that include paramedical, nurse, midwives and then the lay. Only to a certain percentage, because they cannot outnumber the medical professionals. This is now my way of expanding the membership base, to expand the reach of the stakeholders and hopefully by doing that we’d be able to achieve more.

“We want to emphasize on greater collaboration with our regional counterparts. We’re now in communication with some other society presidents in Singapore, Indonesia, and Malaysia. And we all believe that the way to go is to collaborate, we share resources, we share manpower, we share research.”


There’s always something noble in pursuing diseases related to the heart. The seat of emotions, the seat

of feelings, everything emanates from there.

So, why not?

‘‘MT: What is the role of the Philippine College of Cardiology?

SJ: “The Philippine College of Cardiology is the academic arm and the one in charge of giving examinations, conferring the diplomate and fellow status. That’s the academic arm of the association. The non-academic functions – scientific meetings, conventions, continuing medical education – these would fall under the jurisdiction of the Philippine Heart Association

“It’s just a distinction that there’s a separate college for this function, similar to the American Heart Association and American College of Cardiology. Yun nga lang, sa States, meron silang separate conventions. We still don’t do that, we just have one central convention.”

MT: What are the benefits of holding annual conventions?

SJ: “It’s the main event of the entire year in so far as the continuing medical education is concerned. It’s a time to really provide the updates, the developments, the advancements; time to present all the research work that have been accomplished throughout the year. So it’s a meaningful opportunity for all the members to renew their commitment to the association, the time for them to again revisit their links to the association and to get the necessary updates.”

MT: What are the challenges in managing a large society?

SJ: “Well, the challenge is always, this is cliché already, you have to get as many members as motivated and committed as you would want them to be. For one, many members, and I cannot blame them, they

all have their own preoccupation: family, practice, career and other things. So, you try to insinuate the association between those priorities to be able to get through. And sometimes you succeed, sometimes you don’t. But I guess it’s also how you approach the constituents. It’s a common problem among most associations, especially if you are geographically separated. But the text messaging and email are making it less of a problem; and internet and the website are making it manageable.”

MT: What are the challenges in dealing with Filipino patients?

SJ: “They are more knowledgeable. I’d say they are more educated because everything is within the reach of anyone who has a cell phone, who has Wi-Fi, who has internet. You recommend something, before you know it, they’ve already googled it. Magre-recommend ka pa lang, ‘Doctor, I want this kind of stent. Doctor I want this kind of medicine because according to what I searched there are less side effects with this.’

“Sometimes it’s also problem, because you know how the saying goes: A little learning is a dangerous thing. There are people who’d come, ‘I don’t like that doctor because according to the internet it can give this kind of side effect.’ So, without even doing anything, you’re stopped.”


MT: What is the most fulfilling aspect of your position?

SJ: “It’s the realization that there are things you can accomplish. You’re capable pala of effecting some changes in the field you are a part of. Very simple things like training programs of the different institutions that are accredited by PHA. You have a stake on what goes on in their program. Or in the annual conventions. You have a stake on where to direct the healthy lifestyle campaign. You have a stake on what collaborations you want to pursue with your regional counterparts. You have a stake on your partnerships with the department of health, with the department

of education. There are so many lines where you realize that there are things that you can change.

“Financially, wala yan. Actually, you get precious time from your clinic to be able to do these things but as we all say, it’s not just the money that can drive people to do things beyond what they’re supposed to.”

MT: Why should one choose to specialize in cardiology?

SJ: “There’s always something noble in pursuing diseases related to the heart. The seat of emotions, the seat of feelings, everything emanates from there. So, why not?”

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Philippine Heart Association supports Sin Tax Bill

The Philippine Heart Association recently released and official statement support the pas-sage of Senate Bill 3249 - An Act Restructuring the Excise Taxes on Alcohol and Tobacco Prod-ucts (corresponding to a revised version of House Bill 5727), or the Sin Tax Bill.

The society believes it is the moral responsi-bility of its members to support initiatives that will have great impact on prevalent tobacco consumption in the country. According to the American Cancer Society, cigarette smoke con-tains nearly 4,000 chemicals of which 60 are proven cancer-causing agents, the document stated.

“Ten Filipinos die from tobacco use every hour. Smoking is the most common risk factor associated with deaths due to stroke and heart attack in the Philippines. Cigarette smoking kills nearly 87,600 Filipinos every year (or 240 deaths every day) 2 – which is HIGHER than other risk factors like diabetes, hypertension, obesity and high cholesterol,” according to PHA.

Based on the World Health Organi-zation’s MPOWER report in 2009, the Philippines has one of the lowest prices of cigarettes and alcohol in the ASEAN region, giving the poor and the younger population easy access to both. The 2009 Philippines Global Adult Tobacco Survey estimated that more than 17 million of the population aged 15 years and older currently smoke tobacco.

PHA explained that smoking rates are highest among the poor in the ASEAN region, and they will suffer from the cost of long-term treatment. PHA acknow-ledged that the Sint Tax Bill can provide additional financial support for the universal health care program of the government.

“We, as healers of hearts and advocates of heart wellness, believe that it is our moral responsibility to lend our voice and support to this crucial law. We strongly urge our lawmakers to pass the Sin Tax bill NOW,” stated PHA.


MARKET WATCH

For Women in Science (FWIS) Program, a joint ef-fort between L’Oréal Philippines and UNESCO,

awarded Dr. Ma. Cecilia Conaco and Dr. Aletta Yñiguez as the second batch of FWIS National Fellows. Dr. Conaco received the fellowship grant for her research proposal entitled Dynamic Gene Regulation in Marine Sponges, which aims to identify novel sponge genes and the mechanism that allow the organism to monitor and adapt to its environment. Dr. Yñiguez received the grant for her proposal Enhancing robustness of plankton models and monitor-ing systems by understanding fine-scale biophysical processes, which aims to understand the marine environment and its components. Both scientists will be awarded PhP400,000 grants each to aid their research. “Through the FWIS Program we have encountered so many exceptional women and heard their incredible stories of hard work and dedication. It is very heart-warming to know that through the program, we have somehow helped bring these women a step closer to achieving their dreams and move science forward,” said Pamela Picazo-Garcia, L’Oréal Philippines Corporate Communications Manager.

L’Oréal Philippines awards exceptional female scientists

Abbott recently announced the launch of Similac Mom, a nutritional supplement for the expectant

and breastfeeding mothers, which helps support both the baby’s optimal development and the mother’s health. “Complete nutrition during pregnancy and lactation is a key element to good health for both the mother and the baby. Similac Mom complements the nutrition that women and babies would be getting from their diet,” said Dr. Jose Rodolfo Dimaano, regulatory and medical director of Abbott Nutrition International-Philippines. Similac Mom provides key nutrients for baby’s brain and visual nerve development. It offers the Immunify System for better immune system and digestion. It contains 24 essential vitamins and minerals, including nutrients for growth and bone development. It is also fortified with DHA to support the needs of the mother and the developing baby, and prebiotic fiber to support digestive health and improve calcium absorption. Similac Mom is now available in retail stores nationwide. It can be consumed as a drink or as a protein-rich snack.

Providing nutrition for pregnant women


MARKET WATCH

T he new Sensodyne Repair and Protect toothpaste from GlaxoSmithKline (GSK)

Consumer Healthcare is the first daily fluo-ride toothpaste from Sensodyne that contains advanced Novamin® technology. “Tooth sensitivity is very common, yet many do not know the signs. Worse, some actually choose to dismiss them,” said Dr. Angie De Cas-tro, a dental practitioner. “Even the occasional pangingilo, is a sign of sensitivity, which means that the teeth have vulnerable areas,” she added. Novamin® is a clinically-proven patented formula that seeks out and attaches to areas of teeth that are sensitive. Sensodyne Repair & Protect helps repair sensitive areas, using minerals that are the natural building blocks of teeth. “Using Sensodyne Repair and Protect as a regular toothpaste, twice daily, helps to continually repair and protect sensitive areas of your teeth,” emphasized Barbie Dapul from GSK Consumer Healthcare, head of marketing.

Philippine pharmaceutical industry’s future discussed

Sensodyne eases sensitive teeth

Meiven Marketing and Consulting, Inc. recently held a one-day forum that discussed the future of the

Philippine pharmaceutical industry, which was held at the Mandarin Oriental Manila Hotel in Makati City. The event was attended by renowned speakers from the pharma-ceutical industry as well as those coming from regulatory bodies. The forum highlighted the growth forecast for the Philippine pharmaceutical Industry in the next five years, the future of generic drugs in the retail business, the emerging “sunrise” segment of nutraceuticals, the role of pharmaceutical manufacturers in meeting the requirements for GMP, the role of Philippine FDA in regulating the quality assurance for essential medicines, and the perspective of a medical practitioner on the role that pharmaceutical industry players must take in future scenarios. Speaking at the Forum were DOH consultant Dr. Anthony Leachon, IMS Health Country Manager Romeo Z. Castro, Jr., Sydenham Laboratories president Michael Francis Dela Cruz, FDA chief of regulation II Jesusa Joyce Cirunay, Erikagen president Teodoro Ferrer, and CHIPI Presi-dent Albert Garcia.


MARKET WATCH

M SD launched a new educational cam-

paign on eczema with the help of its over-the-counter medication Elica, which is formulated to help manage symptoms of eczema. The campaign features a celeb-rity family that experienced eczema first-hand: the Pangilinan family. “Of my five children, three have eczema. Pabalik-balik ‘yun. Namana kasi nila. Hannah, my third child, has the worst eczema. She has the most eczema flare-ups,” shared Maricel Laxa-Pangilinan. The reality is that eczema can easily be misconstrued as a simple rash and may not be given the proper attention it needs. Rashes may worsen, producing intense itching especially at night time. This may lead to sleep deprivation in affected children. For parents, on the other hand, this may mean nightly sleep interruption of 1-2 hours and time off from work for doctor visits or home care. Elica is available at leading drugstores nationwide. It comes in a 5g cream and 5g ointment, both retailing for Php428.

GE launches ASEAN Healthymagination College

Relieving eczema with Elica

G eneral Electric (GE) officially launched the ASEAN Healthymagination College last August

at the Makati Shangri-La Hotel. This is a bi-annual healthcare educational roadshow which coincided with the staging of GE’s first “Innovation Day” in the country. “Healthcare is something we have always been passionate about. We’re doing this for our friends in the media who we consider our staunch partners in disseminating important and critical information that impact global healthcare,” said Tommy Tan, director of Government Affairs & Policy, GE Healthcare Asia. “Healthcare in the Philippines is a national concern and we are optimistic that this event will deliver posi-tive insights on improving the quality of healthcare and patient care in the country through GE’s life-changing innovations and technology,” shared Jocot De Dios, CEO of GE Philippines. GE Healthcare continues to pursue its initiative by introducing health and medical innovations such as low-cost digital x-ray, portable ultrasounds and more affordable cardiac equipment to reach both the urban and rural areas in the country.

GE V-Scan, a hand-held visualization tool powered by ultrasound technology

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31 October 2012 Conference Coverage

First global standards on assessing lung function

European Respiratory Society Annual Congress, 1-5 September, Vienna, Austria

Rajesh Kumar

The first global standards on assessing lung function in different age groups and ethnicities, established through

international collaboration, promise to revolutionize the way physicians diagnose and manage lung disease.

Spirometry is the standard test for measuring lung function. In the absence of a global benchmark for interpreting its results, someone described as abnormal in one clinic can be labeled as normal in another. Also, an adolescent can see his/her level of lung func-tion decrease dramatically when the care is transferred from pediatric to adult clinic. Sim-ilar errors can occur if the individual patient’s ethnicity and associated difference in body composition or stature are not taken into ac-count.

Multinational researchers part of the Global Lung function Initiative (GLI) 2012, set up by the European Respiratory Soci-ety to establish a consensus on the topic, assessed data from 74,187 healthy non- smokers aged 3 to 95 years to derive reference spirometric prediction equations for Caucasians (N=57,395), African Americans (N=3,545), and North (N=4,992) and South-east Asians (N=8,255), including appropriate age-dependent lower limits of normal. [ERJ 2012: DOI: 10.1183/09031936.00080312]

Forced expiratory volume in 1 second

(FEV1) and forced vital capacity (FVC) between ethnic groups differed proportion-ally from that in Caucasians. For individuals not represented by the above four groups, or of mixed ethnicity, a composite equation tak-en as the average of the above equations was established.

“The first standard lung growth chart developed as a result of these equations will help better identification of children most likely to benefit from treatment, thereby avoiding unnecessary medication for those who don’t need it,” said Dr. Janet Stokes of the Great Ormond St Hospital in London, UK, while describing the clinical implications.

The chart will also improve diagnosis and management of chronic obstructive pulmo-nary disease, thus enhancing independence and quality of life in the elderly, said Stokes.

The GLI-2012 lung growth chart will also allow patients to understand the health of their lungs and more effectively manage their condition, or take steps to prevent develop-ment or progression of lung disease, added Ms. Monica Fletcher, chair of the European Lung Foundation in Sheffield, UK.

Subsequent additional data from the Indian subcontinent, Arab, Polynesian, Latin American countries, and Africa will further improve the equations in the future. How-ever, their widespread use will depend on timely implementation by manufacturers of spirometry devices, said the researchers.


Home factors impact on kids’ asthma medication compliance Elvira Manzano

Family lifestyle and issues at home may negatively affect children’s adherence to asthma medication.

In a study of 93 children with asthma conducted in the Netherlands, 72 percent used >80 percent of prescribed doses for asthma. However, almost 30 percent had poor adherence rates. Barriers to adherence include parental and financial problems, as well as having busy parents. Another common and striking finding was that children (8 to 12 years) were given full responsibility to take their medication with-out parental support or supervision, resulting in poor adherence. [ERJ 2012. E-pub ahead of print]

The findings emphasized how crucial it is for health care professionals treating children with asthma to carefully assess these potential barriers so that appropriate interventions can be put in place to correct the problems, said lead study author Dr. Paul Brand, from the University Medical Centre, Groningen, Netherlands.

“Good adherence is achievable. In fact, median adherence rate in the study was 93 percent at first month and 90 percent at third month. But when we conducted in-depth interviews on 20 parents, 12 with low adherence and 8 with high adherence, as to what might be preventing their children from following their treatment plan, they presented several lifestyle factors,” Brand said.

Some parents, the “delegators” and “ strugglers,” did not succeed in getting their children to take their medication prop-erly. They said a range of things going on in their lives prevented their children from adhering to the treatment plan. Their responses included: “when he was 8, we felt that he got to take [the medication] himself.” One parent even said: “Forcing never works…it becomes a struggle, and we never do that.”

Their answers were compared using an electronic monitoring system. Although parents in the low adherent group expressed intentions to strictly follow the treatment plan at the outset, they failed to do so during the course of the study, Brand said. “Struggling families therefore require tailored support.”

Some parents do not succeed in getting their kids with asthma to take their meds.


33 October 2012 Conference CoverageHe said comprehensive asthma care may

prevent intentional non-adherence, and addressing parental illness and medication beliefs is important. “Excessive responsibility for medicines to school-aged children drives non-adherence,” he concluded.

The results were supported by Mr. David Supple, a parent of an asthmatic child. Speaking about his own experience, he said:

Inhaled glutathione may help cystic fibrosis patients Radha Chitale

A preliminary trial on inhaled glutathione (GSH) showed that it can improve lung capacity in cystic

fibrosis (CF) patients with moderate to severe airways obstruction.

CF is a chronic genetic disease that causes mucus to build up in the lungs, diges-tive tract, and other areas of the body, and affects about 70,000 people worldwide, many of them children.

Glutathione is an antioxidant therapy used as a first-line defense for the lungs against oxidative stress.

Lead researcher Dr. Cecilia Calabrese of Second University of Naples in Italy report-ed that three previous studies on inhaled GSH in CF patients have shown promising outcomes in terms of forced expiratory vol-ume in 1 second (FEV1) and peak expiratory flow, but these were performed on a limited number of patients and only one study was placebo-controlled.

In the current trial, 94 CF patients from Italy over age 6 were divided into a pedi-

atric group (6-18 years) and an adult group (>18 years) and randomized to inhaled GSH (10 mg/kg) or placebo.

Patients were excluded from the trial if they demonstrated a decrease in FEV1 greater than 15 percent during a GSH inhalation test, where FEV1 is evaluated before inhalation and 10 and 60 minutes after inhalation.

FEV1 was evaluated with spirometry at months 1, 3, 6, 9 and 12. Patients were questioned about their lifestyle, frequency of exacerbations, hospital admissions and antibiotic use at months 1, 6 and 12.

Preliminary results showed that inhaled GSH is well tolerated by both pediatric and adult CF patients.

Pediatric patients on GSH therapy did not demonstrate significant increases in FEV1 at 3 and 6 months after beginning therapy com-pared with the placebo group. Mean FEV1 levels at months 0, 1, 3 and 6 were 95.6 ± 22.6 percent, 96.3 ± 23.1 percent, 96.4 ± 19.5 percent and 97.1 ± 20.8 percent in the GSH group, respectively, and 101.1 ± 17.8 percent, 98.3 ± 15.3 percent, 100.4 ± 18.7 percent and

“It can be chaotic having four children and when we have given our son, Alex, respon-sibility over his medication to control his asthma, we have found his adherence slip away. We are conscious of this now and would encourage other parents to keep a close eye on their child’s level of adherence, and to spot potential barriers before they become a problem.”

34 October 2012 Conference Coverage98.6 ± 19.3 percent in the placebo group, re-spectively.

Adults did show moderate increases in FEV1 with GSH therapy compared with placebo but this trend did not reach significance after 6 months. Mean FEV1 levels at months 0, 1, 3, and 6 were 63.3 ± 15.3 percent, 68.1 ± 17.4 percent, 67.3 ± 16 percent and 67.0 ± 16.5 percent in the GSH group, respectively, and 66.7 ± 21.3 percent, 66.5 ± 18 percent, 64.5 ± 18.9 percent and 64.0 ± 20.2 percent in the placebo group,

respectively. However, pooled data on all patients

with FEV1 ≤80 percent showed that signifi-cant improvement persisted 6 months after beginning therapy. Mean FEV1 increased to 62.6 ± 15/1 percent at 6 months from 58.3 ± 13.2 percent at baseline (P=0.04).

“Preliminary results seem to show that inhaled GSH therapy is able to induce a significant increase of FEV1 in CF patients affected by moderate to severe airway obstruction,” Calabrese said.


Long-distance running raises pulmonary edema riskDr. Yves St. James Aquino

A recent study found that marathon running can trigger pulmonary edema, which may be associated with

physical signs of breathlessness, severe cough and heart attack or respiratory failure in severe cases.

“Marathon running is worldwide. Half-a-million people ran the marathon in the United States this past year and in 2010. And therefore, this is a big topic,” said lead author Dr. Gerald Zavorsky.

Researchers from the US and Italy aimed to determine if pulmonary edema devel-ops from long-distance running, character-izing its incidence and severity. In addition, researchers wanted to determine if the resulting edema is related to finishing time.

The study involved 26 runners who partici-pated in the 2011 Steamtown Marathon held in Scranton, Pennsylvannia, US. The marathon started at an elevation of 452 meters above sea

level, with a net drop to 291 meters at the finish line. The study noted that all runners finished with times between 142 and 289 minutes.

Half of runners tested within 20 minutes of completing a marathon had

some level of pulmonary edema.

35 October 2012 Conference CoverageTo quantify the presence of edema, postero-

anterior and lateral chest radiographs of the run-ners were taken the day before the race, then 19, 56 and 98 minutes after finishing the race. Three radiologists were tasked to do the radiograph interpretation. The readers worked indepen-dently and were not in contact with each other. They were also not told which radiographs were taken before or after the race.

Four radiographic characteristics were assessed, including peri-bronchial cuffing, loss of definition of vascular markings, pulmonary opacification and blurring of hilar silhouette. The quantification of edema ranged from 0 or no edema to 8 or severe edema. The scores from each reader were then averaged.

Results showed that 50 percent of run-ners had some level of pulmonary edema 20 minutes after the race, and 20 percent of those runners develop moderate to severe pulmonary edema. In four runners (15 percent), mild to moderate pulmonary edema was even retained 1 hour after finishing the marathon.

Upon further evaluation, the study found

that women were at 13 times higher risk com-pared with men in the development of pulmo-nary edema (odds ratio 12.8, r2 0.31, P=0.038). No correlation was established between mara-thon time and the development of pulmonary edema, which suggests the risk of edema may be prevalent across all abilities.

However, none of these athletes with radio-logic finding of pulmonary edema exhibited signs such as difficulty of breathing or coughing of blood.

According to Zavorsky, potential causes may include stress failure of pulmonary capillar-ies, fluid-electrolyte imbalances, and increased permeability pulmonary edema. However, the most likely cause is increased pulmonary wedge pressure, whereby pressure within pulmonary artery force out fluid into the interstitium.

“While pulmonary edema can be a negative consequence of marathon running, regular exercise can also keep you fit and healthy. We do not yet know the impact of this finding on long-term health of runners,” concluded Zavorsky.

36 October 2012 Conference CoverageFlight hypoxia assessment inappropriate for pediatricsDr. Yves St. James Aquino

British Thoracic Society (BTS) recommendations on hypoxic flight assessment are not appropriate for

pediatric patients, according to a study by UK researchers.

The study involved 107 children age 0.1 to 19.2 years who were referred for a variety of conditions including muscular dystrophy, cystic fibrosis, severe asthma, long-term ventilation, long-term oxygen therapy and sleep breathing disorders.

The BTS recommendations aim to enhance safety for passengers with lung problems who are travelling by air, reduc-ing the number of in-flight emergencies due to respiratory disease. The BTS established upper and lower thresholds for “no in-flight oxygen required” at percutaneous oxygen saturation (SpO2) >95 percent or “in-flight oxygen needed” at SpO2 <92 per-cent.

The study was a retrospective audit of patients referred to a pediatric respirato-ry function laboratory. The hypoxic chal-lenge test as described by Gong et al sug-gests the maximum cabin altitude of 2,438 meters (8,000 feet) can be simulated at sea level with a gas mixture containing 15 per-cent oxygen in nitrogen [Am Rev Respir Dis 1984;130:980–6].

According to the researchers, the test protocol used 100 percent nitrogen to dilute the contents of a body plethysmograph to a fraction of inspired oxygen (FiO2) of 15 percent, before assessing the SpO2 profile

for 20 minutes. Based on the BTS criteria, failure in the hypoxic challenge constituted a mean SpO2 of less than 90 percent when breathing FiO2 15 percent. Hypoxic chal-lenge testing is the pre-flight test of choice for patients with hypercapnia, according to BTS [Thorax 2002;57:289–304].

Results showed that out of the 107 chil-dren, of which 58 percent were female, 83 percent (N=89) had a baseline SpO2 of greater than 95 percent in FiO2 21 percent. In addition, 29 percent of the patients were noted to be hypoxic in FiO2 15 percent.

The study noted that if BTS criteria were to be applied in this pediatric sample, 17 percent (N=18) would be referred and only 10 percent (N=11) would be detected with hypoxia at mean SpO2 of <90 percent in FiO2 15 percent. However, if all referrals regardless of the BTS criteria will be as-sessed, 35 percent would be detected to have hypoxia. For mean SpO2 desaturation to <85 percent, use of BTS criteria would result in detection of 6.5 percent of cases versus all referral detection of 15 percent.

Based on the results, the BTS recom-mendations for referral for hypoxic flight assessment are not appropriate for pedi-atrics, according to the study. It added that using sea level SpO2 <95 percent as a cutoff for referring patients will result in detection of fewer patients who desatu-rate in hypoxic conditions. Researchers concluded that children with respiratory disease should be considered for a hypox-ic challenge test irrespective of sea-level SpO2 percent.


Personal Perspectives

‘‘ One of the major activities of the European Respiratory Society is this annual congress and it’s been steadily growing, growing not only in numbers, it’s been growing in importance, it’s growing in global perspective… For lung diseases, there is a huge disparity in health care models, huge disparity in how to care for certain patients. Infectious diseases, HIV/AIDS, lung cancer, COPD are diseases that you know occur everywhere.

Dr. Klaus Rabe, President, European Respiratory Society, Professor, University of Kiel, Germany

It’s been an adventure. It’s good because we could just go anywhere we want to go. For the lectures… it is subdivided into four topics. If you do not want the next topic, you go to the next hall. We try to find topics that are relevant to our subspecialty. We just attended a pulmonary rehab session, because of the updates and we plan to set up our own program.

Dr. Ma. Bernardita Chua, Consultant, Perpetual Succour Hospital of Cebu, Philippines

‘‘

It’s already my fourth ERS, and I’m a PhD fellow. The topics of my PhD which I can also follow here are physical activities and comorbidities in COPD patients. There are a lot of sessions I have checked in my personal agenda. They were very good; the symposia especially are very nice.

Hans van Remoortel, PhD Fellow, University Hospital Gasthuisberg, The Netherlands

‘‘

The topics I attended were not too bad. It depends on the subject. Yesterday, I attended four sessions which were very interesting. The topics I’m interested in are COPD, pulmonary hypertension, interstitial lung disease and infections.

Dr. Masoongo Masoongo, Consultant, Arras Hospital, France

‘‘

38 October 2012 Conference CoverageEuropean Society of Cardiology Congress, 25-29 August, Munich, Germany

Aspirin can be dropped in PCI patients on oral anticoagulantsChristina Lau

Patients on oral anticoagulants (OAC) undergoing percutaneous coronary in-tervention (PCI) should be treated with

clopidogrel, but not aspirin, according to the first randomized trial to assess optimal antithrom-botic therapy in this high-risk group of patients.

The trial showed that dual therapy with OAC and clopidogrel causes less bleeding than triple therapy with OAC, aspirin and clopidogrel, and is safe with respect to preventing thrombotic and thromboembolic complications.

“Long-term OAC therapy is obligatory in most patients with atrial fibrillation (AF) and in those with mechanical heart valves. Over 30 percent of these patients have concomitant isch-emic heart disease and, if they need to undergo PCI, aspirin and clopidogrel are indicated,” said lead investigator Professor Willem Dewilde of the TweeSteden Hospital in Tilburg, the Nether-lands.

“Until now, no prospective randomized data were available on the optimal antithrombotic therapy for these patients,” he continued. “Al-though triple therapy seems logical for the pre-vention of stroke and stent thrombosis, it often causes serious bleeding complications and the need to discontinue aspirin and clopidogrel.”

The WOEST* study included 573 patients from the Netherlands and Belgium, who were already on OAC for AF or mechanical valves and were undergoing PCI. The primary endpoint was occurrence of all bleeding events after 1 year, classified according to the TIMI (Thrombosis in Myocardial Infarction) bleeding criteria. Second-

ary endpoints were the combination of stroke, death, MI, stent thrombosis and target vessel re-vascularization, and all individual components of the primary and secondary endpoints.

“At 1 year after PCI, patients in the dual ther-apy group had significantly lower incidence of bleeding (19.5 vss 44.9 percent; HR=0.36; P<0.001] and overall mortality [2.6 vs. 6.4 per-cent; HR=0.39; P=0.027) than those in the triple therapy group,” reported Dewilde. “They had no increase in thrombotic or thromboembolic events compared with those on triple therapy.”

Although the trial was open-label and had a limited number of patients, Dewilde suggested that the findings have important implications for future treatment and guidelines. “We propose that a strategy of OAC plus clopidogrel, without aspirin, could be applied in this group of high-risk patients on OAC when undergoing PCI,” he said.

Commenting on the findings, discussant Dr. Marco Valgimigli from Ferrara, Italy pointed out that one bleeding event could be avoided by omitting aspirin in only four patients. “While the reductions were mostly in minimal [6.5 vs. 16.7 percent] and minor bleeding [11.2 vs. 27.2 per-cent], the difference in major bleeding between the dual and triple therapy groups might have become significant with larger numbers,” he said. “With the important findings from WOEST, the taboo of discontinuing or omitting aspirin in the contemporary environment has been broken.”

*WOEST: What is the Optimal antiplatElet and anticoagulant therapy in

patients with oral anticoagulation and coronary StenTing

39 October 2012 Conference CoverageInvestigational drug shows promise in HFChristina Lau

A novel angiotensin receptor ne-prilysin inhibitor – LCZ696 – has demonstrated beneficial effects in

heart failure (HF) patients with preserved ejection fraction in a phase II trial.

LCZ696 is a first-in-class agent comprising the molecular moieties of a neprilysin inhibitor and the angiotensin receptor inhibitor (ARB) valsartan as a single compound. Its dual mechanism of action is believed to restore the altered neurohormonal balance in HF with preserved ejection fraction.

In the PARAMOUNT* study, the efficacy and safety of LCZ696 was compared with that of valsartan in 308 patients from 13 countries. [Lancet 2012; DOI:10.1016/S0140-6736(12)61227-6]

“HF with preserved ejection fraction accounts for up to half of HF cases, and is associated with substantial morbidity and mortality. However, no therapies have been shown to improve clinical outcomes in this condition,” said lead investigator Professor Scott Solomon of the Harvard Medical School and the Brigham and Women’s Hospital in Boston, Massachusetts, US.

Results showed that after 12 weeks of therapy, LCZ696 significantly reduced levels of NT-probBNP by 23 percent compared with valsartan (P=0.005). “NT-proBNP is a marker of cardiac wall stress, and levels are increased in HF patients,” explained Solomon. “The greater reduc-tion in NT-proBNP achieved with LCZ696 was sustained to 36 weeks, although the

difference vs. valsartan was no longer significant.”

Patients treated with LCZ696 also had reduced left atrial size and improved symptoms (as measured by New York Heart Association [NYHA] Functional Classifica-tion), both of which became significant vs. valsartan by week 36.

“LCZ696 was generally well tolerated, with fewer serious and overall adverse events than valsartan,” said Solomon. “Results from PARAMOUNT are encourag-ing, and LCZ696 is currently being tested in a trial of 8,000 HF patients with reduced ejection fraction.”

In another study, spironolactone was shown to improve cardiac function and structure, and reduce neuroendocrine activation in 422 patients with symptomatic diastolic HF.

“In the international phase IIb Aldo-DHF trial, 12-month treatment with the aldosterone receptor antagonist improved diastolic function, induced structural reverse remodeling, and reduced NT-proBNP levels and blood pressure compared with place-bo,” reported Professor Burkert Pieske of the Medical University of Graz in Austria. “How-ever, the treatment did not improve exercise capacity, NYHA class or quality of life.”

Spironolactone was shown to be safe, with-out severe adverse events. “The drug can be considered in patients with diastolic HF, for improving cardiac function and blood pres-sure control,” suggested Pieske.

*PARAMOUNT = Prospective compArison of ARNI with ARB on

Management Of heart failUre with preserved ejectioN fraction

**Aldo-DHF = Aldosterone Receptor Blockade in Diastolic Heart Failure

40 October 2012 Conference CoverageNiacin/laropiprant well tolerated in HPS2-THRIVE trialAlexandra Kirsten

More than three-quarters of patients taking long-term extended release niacin/laropiprant (ERN/LRPT)

in the HPS2-THRIVE* trial have tolerated treatment, according to preliminary results.

HPS2-THRIVE is the largest study so far to assess whether adding ERN/LRPT to statin therapy can further lower cardiovascular risk.

In the trial, a total of 25,673 patients with occlusive arterial vascular disease from the UK, Scandinavia and China were randomized to receive long-term treatment with either ERN/LRPT 2 mg or placebo, in addition to simvastatin therapy. The primary endpoint included major vascular events after a median follow-up of 4 years.

The preliminary results suggest that about 76 percent of the patients can tolerate long-term ERN/LRPT treatment.

A safety analysis suggested that myopathy occurred in 0.5 percent of patients treated with simvastatin 40 mg and ERN/LRPT, however, the vast majority of these cases were found in patients with Chinese descent.

”These observations have resulted in a label change for simvastatin and ERN/LRPT,” explained lead study author Professor Jane Armitage, consultant in Public Health

Medicine at the University of Oxford, England, adding that patients of Chinese descent should not receive simvastatin 80 mg with cholesterol-modifying doses of niacin-containing products.

Niacin did not show any clear adverse effects on the liver in the trial, but known cutaneous and gastrointestinal side effects were confirmed.

Niacin has been shown to be an effec-tive HDL-raising agent, but randomized trial evidence for beneficial cardiovascular effects is limited. Most previous studies have been performed using fibrates, which raise HDL cholesterol only modestly, and those studies produced mixed results. Moreover, the tolera-bility of niacin has been limited by flushing and cutaneous side-effects, which appear to be mediated largely by prostaglandin D. These side effects can be substantially reduced by laropiprant, a selective prostaglandin D receptor antagonist.

Further results from the HPS2-THRIVE are expected to be released in 2013.

*HPS2-THRIVE: Heart Protection Study 2 -Treatment of HDL to Reduce the

Incidence of Vascular Events

Niacin has been shown to be an effective HDL-raising agent.

The preliminary results

suggest that about 76 percent

of the patients can tolerate long-term ERN/

LRPT treatment

‘‘

42 October 2012 Calendar

October23rd Great Wall International Congress of Cardiology (GW-ICC) – Asia Pacific Heart Congress (APHC) 201211/10/2012 to 14/10/2012Location: Beijing, ChinaInfo: Secretariat Office of GW-ICC & APHC (Shanghai Office)Tel: (86) 21-6157 3888 Extn: 3861/62/64/65Fax: (86) 21-6157 3899Email: [email protected]: www.heartcongress.org

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

8th Asian-Pacific Society of Atherosclerosis and Vascular Diseases Meeting 20/10/2012 to 22/10/2012 Location: Phuket, Thailand Info: Asian-Pacific Society of Atherosclerosis and Vascular DiseasesTel: (66) 2940 2483 Email: [email protected]: www.apsavd2012.com

November

2012 Scientific Sessions of the American Heart Association 3/11/2012 to 7/11/2012 Location: Los Angeles, California, US Info: American Heart Association Tel: (1) 214 570 5935 Email: [email protected] Website: www.scientificsessions.org

8th International Symposium on Respiratory Diseases & ATS in China Forum 20129/11/2012 to 11/11/2012Location: Shanghai, ChinaInfo: UBM Medica Shanghai Ltd.Tel: (86) 21-6157 3888 Extn: 3861/62/64/65Fax: (86) 21-6157 3899Email: [email protected]: www.isrd.org

63rd Annual Meeting of the American Association for the Study of Liver Diseases9/11/2012 to 13/11/2012 Location: Boston, Massachusetts, US Info: American Association for the Study of Liver Diseases Tel: (1) 703 299 9766 Website: www.aasld.org

UpcomingNational Diagnostic Imaging Symposium 2/12/2012 to 6/12/2012Location: Orlando, Florida, USInfo: World Class CME Tel: (980) 819 5095Email: [email protected]: www.cvent.com/events/national-diagnostic- imaging-symposium-2012/event-summaryd-9ca77152935404ebf0404a0898e13e9.aspx

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

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

43 October 2012 Calendar

54th American Society of Hematology Annual Meeting8/12/2012 to 11/12/2012Location: Georgia, Atlanta, USInfo: American Society of HematologyTel: (1) 202 776 0544Fax: (1) 202 776 0545Website: www.hematology.org

17th Congress of the Asian Pacific Society of Respirology14/12/2012 to 16/12/2012Location: Hong KongInfo: UBM Medica Pacific LimitedTel: (852) 2155 8557Fax: (852) 2559 6910E-mail: [email protected]: www.apsr2012.org

16th Bangkok International Symposium on HIV Medicine16/1/2013 to 18/1/2013Location: Bangkok, ThailandInfo: Ms. Jeerakan Janhom (Secretariat)Tel: (66) 2 652 3040 Ext. 102Fax: (66) 2 254 7574E-mail: [email protected]: www.hivnat.org/bangkoksymposium

28th Congress of the Asia-Pacific Academy of Ophthalmology17/1/2013 to 20/1/2013Location: Hyderabad, IndiaInfo: APAO SecretariatTel: (852) 3943 5827Fax: (852) 2715 9490 Email: [email protected]: www.apaoindia2013.org

Asian Pacific Society of Cardiology 2013 Congress21/2/2013 to 24/2/2013Location: Pattaya, ThailandInfo: Kenes Asia (Thailand Office)Tel: (66) 2 748-7881Fax: (66) 2 748-7880Email: [email protected]: http://www2.kenes.com/apsc2013/pages/home.aspx

44 October 2012 After Hours

Radha Chitale

When they first went up, the enormous splayed towers encased in geometric scaffolding, what would become “supertrees,” standing bare behind the Marina Bay Sands hotel in Singapore recalled a factory more than a home

for flora and fauna. But my recent visit to the National Parks Board’s ambitious Gardens by the Bay

show the area has transformed from a wasteland of construction into a unique botanical park well on its way to becoming an iconic example of sustainability in urban landscaping.

The over S$1 billion project covers 101 hectares of reclaimed land and includes lakes, sky walks, cultural gardens and two biomes that house 220,000 plant varieties from around the world.

The supertrees are clustered in several spots around the park and are vertical


gardens between 25 and 50 meters high. Their scaffolding holds ferns, flowering climbers and bromeliads that will eventually grow to cover the entire structure.

The towers also function to cool the biomes, are air exhaust receptacles and are fitted with photovoltaic cells that harvest solar energy to light up the supertrees at night.

The horticultural attractions of the Gardens are in the domed glass biomes. Walking into the Cloud Forest biome, one goes from sea level to 1,800 meters

above and the sharp temperature drop is a welcome change from the heat outside. The waterfall at the entryway cascades down a mini mountain top covered in pitcher plants and other flowers and shrubs that thrive in cool, moist conditions.

I may have mistakenly expected a wilderness of scented flowers from the Flower Dome, but the manicured central flower field is colourful enough and made a pretty picture for one couple dressed up for wedding photos, seated on matching forest thrones in a bed of gerber daisies, complete with a small gazebo in the background.

The Flower Dome also features garden plants from a variety of regions such as baobab trees from Africa, wine palms from South America and olive groves from the Mediterranean.

Both biomes end with educational exhibits detailing the carbon cycle, different energy sources, the science of polar ice caps, and threats to plants from urbanization and climate change.

The Gardens manage to incorporate a lot of educational information across the park. Plaques studded among the portion of the Gardens that are free to the public describe the varieties of plants, what their uses are, how sustainable elements have been incorporated into the building and a smorgasbord of trivia.

The plants in the biomes, by contrast, are not obviously labelled, probably to indicate that one should rent the self-guided audio tour.

Beyond well-developed biomes, the Gardens are still a project in progress, with clear spots yet to be filled with plants, evidenced by patches of exposed black soil and empty wiring and trellises for plants to take over.

Although the National Parks Board’s vision of a “City in a Garden” germinated the Gardens by the Bay, the vista of Singapore’s central business district looms over the park creating a sense that this is still a garden – a very large garden – in a city.

But that is a question of semantics. At its most basic, the Gardens by the Bay put more plants in an urban space, and that is a good thing.


Medicinal Plants

Several plants in the Gardens by the Bay have medicinal properties. These plants are located all over the park and are selected because they have strong cultural connections to the garden they are in or they are native to the climate.

Lemon Gum (Corymbia citriodora) Australia Garden, Flower Dome - Relieves arthritic pain, alleviates nasal congestion, antiseptic properties

Tree Aloe (Aloe barberae) South African Garden, Flower Dome - Antimicrobial properties, soothes skin, anti-inflammatory

Monkey Puzzle Tree (Araucaria araucana) South American Garden, Flower Dome - Produces a resin used to treat ulcers and sores

Olive Tree (Olea Europaea) Olive Grove, Mediterranean Garden, Flower Dome - Metabolism inducer, reduced LDL cholesterol, blood pressure,

and blood sugar levels

Lavender (Lavandula dentate) Mediterranean Garden, Flower Dome - Reduces insomnia, alopecia, anxiety, stress-related disorders,

post-operative pain

Tongkat Ali (Eurycoma longifolia) Malay Heritage Garden - Increases testosterone production, anti-malarial and anti-microbial properties

Curry Tree (Murraya koenigii) Indian Heritage Garden - Anti-diabetic, anti-oxidant, anti-inflammatory, hepatoprotective

Camphor (Cinnamomum camphora) Indian Heritage Garden - Anasthetic, anti-microbial

Weeping willow (Salix babylonica) Chinese Heritage Garden - Antirheumatic, astringent, source of salicylic acid

Mulberry (Morus alba) Chinese Heritage Garden - Antimicrobial, antioxidant, hypolipidemic

47 October 2012 Humor

“Do you have to go on and on

about how gross the whole thing is?”

“There’s no cure, because you are perfectly healthy!”

“Don’t try to move or go anywhere. We will be right back!”

“I said I was sorry!”

“If the worst happens, can I keep your lawn mower?”

“What your husband is experiencing, it’s what we call rigor mortis, making it difficult

for him to relax!”

“Sure, some of my patients became very sick after the

operation, and others have died, but none of them seriously!”

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