medical tribune april 2012 hk

7/30/2019 Medical Tribune April 2012 HK

1/66

www.medicaltribune.com

April 2012

Cangrelor BRIDGE to cardiac

surgery for at-risk paents

ACUTE CORONARY SYNDROME

NEWS

Overeang doubles risk ofmemory loss

CONFERENCE

Psoriasis studies show linkwith stress

Diagnoscs for thedeveloping world

FORUM

ESRD paents shiing towardshome dialysis

HONG KONG FOCUS

Bone screening recommended for heart failure patients

Management of

endometriosis

IN PRACTICE


2/66


3/66

3 April 2012

Bone screening recommended forheart failure patients

Rajesh Kumar

Researchers are recommending thatpaents with heart failure be aggres-sively screened for osteoporosis and bonefractures.

In their study, which analyzed data from

45,509 adult subjects undergoing bone min-eral density (BMD) tesng over a 10-year

period, the presence of heart failure wasassociated with a 30 percent increase in majorfractures independent of tradional risk fac-tors and BMD.

Our study demonstrates for the rst methat heart failure and thinning of bones gohand in hand, said lead author Dr. Sumit

Majumdar of the University of Alberta inEdmonton, Canada.

The ndings are relevant for Asians, parc-ularly for Chinese and Japanese populaonsin which rates of osteoporosis and fracture are

higher than those seen in other ethnic groups,

said the researchers.

Of those included in the analysis, 1,841(4 percent) had recent-onset heart failure.

Subjects with heart failure were signicantlyolder (74 vs 66 years), had more previous frac-

tures (21 percent vs 13 percent), and lowertotal hip BMD than those without heart failure

(T-score -1.3 vs -0.9). [JCEM2012; 11:3055-R2]Over an inial 5-year observaon period,

2,703 fractures were reported. Overall, 10percent of heart failure subjects had majorfractures compared with 5 percent of those

without (unadjusted hazard rao [HR] 2.45,95% CI 2.11-2.85). Adjustment for osteopo-

rosis risk factors, comorbidies, and medi-caons weakened but did not eliminate this

associaon (HR 1.33, 95% CI 1.11-1.60) nordid further adjustment for total hip BMD (HR1.28, 95%CI 1.06-1.53).

Osteoporosis and heart failure are common,

chronic and costly condions that share com-mon eologic factors such as older age, post-

menopausal status and diabetes. Previousstudies have suggested that heart failure may

predispose a paent to fractures not onlybecause it increases incidence of falling, butbecause both heart failure itself and its medi-cal treatments can lead to loss of bone mass.

Understanding the mechanism betweenheart failure and osteoporosis might lead to

new treatments for both condions Heart

failure should be treated as a stronger risk fac-tor for fracture, just as the classic risk factorssuch as prior fracture and family history.

Part of screening for osteoporosis should

involve looking at chest X-rays of paents withheart failure, said Majumdar.

Heart failure paents get a lot of X-raysand they oen incidentally show many frac-tures of the spine that would automacally

provide an indicaon of severe osteoporosisand need for treatment.

A large survey of more than 45,000 adults

showed that heart failure was associated with a30 percent raised risk of major bone fractures.


4/66


5/66

5 April 2012 Forum

Diagnostics for the developing world

Based on a lecture by Professor Jon Cooper, chair of bioengineering at the University

of Glasgow in Scotland, UK, organized by the Brish High Commission in Singapore

recently under the auspices of the UK-Singapore Partners-in-Science program.

Developing world diagnoscs is an excit-ing new area. There is obviously thehumanitarian aspect of it in terms of doing

beer for the world. But it also has somevery challenging engineering aspects.

In low income countries, 40 percent of

people die before the age of 14, whereasin high income ones, 70 percent will sur-

vive beyond the age of 70. Most prevent-able deaths in poor countries occur due tove major diseases: tuberculosis, malaria,pneumonia, rotavirus and HIV. Thesediseases are responsible for 7.5 millionworldwide deaths annually.

At the University of Glasgow, we are

working on the development of quickand cheap diagnosc tests, not only forthe major diseases such as malaria andtuberculosis, but also for many of the socalled neglected diseases lymphac l-ariasis, trachoma, leishmaniasis, bilhar-zias (schistosomiasis), sleeping sickness,

river blindness, Chagas disease, leprosyand hookworm disease that massively

impact the lives of millions.Several global health organizaons,

along with the UK and US governments,the Bill and Melinda Gates Foundaon, andsome pharmaceucal companies, recentlypledged to combat 10 such neglected trop-ical diseases over the next decade. Theyaim to eliminate these diseases through a

dramac increase in drugs and treatment

programs in the aected countries. I thinklow cost diagnosc technologies will also

play a key role in this iniave.Technologies that are currently avail-

able in the developing world tend to befairly simple. Malaria tests, for example,typically involve a blood smear, a stain,and a microscope to look for the plasmo-

dium within the red blood cell. To diag-nose sleeping sickness, the demands for

detecon are acute because of a very low

level of parasitemia (perhaps less than oneparasite per 100 million blood cells). Thediagnosc test needs to be able to detectit, and thats quite demanding.

Currently, countries in East and Sub-Sarharan Africa (where sleeping sickness isa problem) have a basic chromatographicexchange column that is used to selecvelyconcentrate the parasites before they are

observed under a microscope. That mightsound like a very successful technique and it


6/66

6 April 2012 Forum

works prey well. But the columns are madelocally and their availability is sporadic.

The technological challenges for devel-

oping diagnoscs for sleeping sickness are

also manifold. The tests need to have a sen-sivity of at least 1 to 100 million or shouldhave the capacity to detect a very small

number of parasites against a very largebackground. They should be able to bedelivered in places where power and infra-

structure is non-existent and they shouldbe very inexpensive. The tests should alsowork under severe ambient condions,

should be easy to use, and be able to han-dle blood, urine or saliva samples.

The requirement is not just to detect theinfecon. Due to growing problem of drugresistance, the tests need to be able to seeif the bacteria or parasite will respond tocommonly used drugs, so we know which

drug to give to paents to treat them suc-cessfully. These laer assays require the

tesng of DNA using a nucleic acid test.Several new technologies are already

under development involving the use of

mobile phones as microscopes and ultralow-cost amenable paper microuidics-based tests.

At the University of Glasgow, we are alsointerested in the use of mobile phones indiagnoscs.

In Africa, there are half a billionmobile phones from the latest 3G onesto those that are 10 to 15 years old withbasic functions. All of them have a bat-tery. We see them more as a source of

rechargeable power supply for very lowpowered diagnostic tests. For diagnostic

tests for malaria, sleeping sickness and

tuberculosis, we are looking at the use of

acoustics and dielectrophoresis for sepa-ration and sensing.

Surface acousc wave technology iscommon in mobile phones. In diagnoscs,when you put uid in the path of thoseacousc waves, the interface between the

chip, the air and the liquids creates the con-dions necessary to separate the sampleinto its dierent components for diagnosis.For malaria, we take a blood sample, per-form a lysis and use PCR amplicaon anddetect the DNA. In 15 minutes, we can run30 PCR cycles which provides clear signals

at 0.07 percent of parasitemia (equivalent

of 10 parasites in a nger prick of blood).

There is possibility of using this test eitherfor tesng for drug resistant malaria (anemerging problem in northern Thailand) orfor mulplexed analysis for malaria, tuber-culosis and pneumonia on the same chip.

It can also check whether the parasite is

resistant to drugs.

In dielectrophoresis, parcles includ-ing cells become polarized within electric

elds and we are looking at how we caninduce these electric elds opcally usinga very low power technique. That essen-

ally works on the basic principle thatmanipulaon of electric charges gives riseto a force. The cells move within the elec-

tric eld based on the magnitude of theforce being exerted and result in bloodmoving in one direcon and trypano-

somes in another. We then use a simplealgorithm to detect the enriched parasites

in the sample.

The challenge for us is tesng anddelivering these assays at a low cost.

Demonstrang that we can now imple-ment technologically advanced assays into

very low cost formats, such as those beingdeveloped in paper based Lab-on-a-chip is

perhaps the most signicant engineeringchallenge we face.


7/66


8/66

8 April 2012 Hong Kong Focus

Aspirin safe for hemorrhagic stroke patients

Naomi Rodrig

Aspirin use in Chinese paents whohad a previous intracranial hemor-rhage (ICH) does not increase the risk ofrecurrent ICH, a University of Hong Kong(HKU) study found. [Thromb Haemost2012;107:241-247]

Aspirin is oen considered unsafebecause of the associated bleeding

risk, parcularly for paents who havehad a previous ICH, said lead studyauthor, Dr. David Siu of the Department

of Medicine. This presents a treat-

ment dilemma because many paentswith previous ICH are also at risk ofcardiovascular disease [CVD] and sllrequire aspirin for CVD prevenon.

The observaonal retrospecve study,

conducted from May 1996 to February2010, included 440 consecuve paentswho presented with a rst spontaneousICH and survived the rst month. Paentswith ICH secondary to trauma, arterio-venous malformaon, aneurysm, tumor,hemorrhagic transformaon or ischemicstroke were not included in the study.

Paents clinical characteriscs, an-

platelet therapy aer ICH, and outcomesof subsequent events (recurrent ICH,ischemic stroke, acute coronary syn-

drome or death) were obtained from hos-pital records.

Of the 440 paents, 56 paents (12.7percent) were prescribed aspirin. Aeran average follow-up of 5 years, 47

paents (10.7 percent) had recurrent

ICH. Paents prescribed aspirin didnot have a higher risk of recurrent ICH

compared with those not prescribed aspi-

rin (22.7 paent-aspirin years vs 22.4 per1,000 paent-aspirin years; p=0.70), theauthors wrote.

A mulvariate analysis of the data fur-ther idened age >60 years and hyper-tension as independent predictors for

recurrent ICH (hazard rao=2.0 for both).A subgroup analysis of 127 paents

with standard indicaons for aspirin

use (atrial brillaon, coronary arterydisease and/or ischemic stroke) found

that ICH recurrence rate among the 56paents who were actually prescribedaspirin was similar to that for paentswho did not receive aspirin (2.3 vs 2.2

percent per year).

In fact, the protecve eect of aspirinwas conrmed, as there was an overall

50 percent reducon in stroke and heartaack in the aspirin group compared withthe non-aspirin group, noted Dr. Jenny

Pu of the Department of Surgery.

Our results reveal that aspirin is not a

risk factor for developing recurrent ICH.Aspirin is protecve against ischemicevents and clinicians should consider pre-

scribing it to Chinese paents with stand-

ard indicaons despite a history of ICH,advised Siu.

Approximately 20,000 people in HongKong experience stroke every year. Thehigh rate of hemorrhagic stroke among

Chinese as compared with Caucasian pop-

ulaons (35 vs 15 percent of all strokes)further underscores the importance of

the study results, indicang that aspirin

can be used safely to protect ICH paentsfrom further CVD events.


9/66


Transforming history of APL in HK

Chrisna Lau

Hong Kong paents with acute pro-myelocyc leukemia (APL) no longerdie of the disease as introducon of oralarsenic trioxide therapy in 1999 has pro-vided an eecve strategy for salvage andprevenon of relapses and substanallyimproved overall survival (OS).

Oral arsenic trioxide has been used

for relapsed APL in Hong Kong since1999. It has completely replaced IV arse-nic, and bone marrow transplantaon isnow reserved for refractory cases only,

said Dr. Wing-Yan Au of the Division ofHematology, Medical Oncology & BoneMarrow Transplantaon of the QueenMary Hospital (QMH), who won the bestabstract award in the leukemia category

at the 3rd Internaonal HematologicMalignancies Conference held recently

in Hong Kong.Oral arsenic trioxide was a stand-

ard leukemia therapy worldwide in the

1940s, and was used at QMH unl the1950s. The drug was then forgoen inthe chemotherapy era. In the 1970s, clini-cians in mainland China started using IV

arsenic trioxide. This was followed by usein New York in the 1990s, and subsequentFDA approval for treatment of relapsedAPL, said Au.

In Hong Kong, researchers at the QMHand the University of Hong Kong devel-oped an oral formulaon of arsenic tri-oxide that has comparable bioavailabilityto the IV formulaon. Use of the oral

therapy has led to a signicant decreasein 5-year relapse rate and a substanal

improvement in 5-year OS.

An epidemiological survey of all APLpaents in Hong Kong in 19912001showed that 5-year relapse rate has

decreased from 54 percent to 16 per-cent, said Au. With blood support andstrategies to prevent or salvage relapses,

5-year OS has jumped from 44 percent to80 percent.

The survey included a total of 408

paents (complete remission [CR],n=318; inducon death, n=88; lost cases,n=2) in four 5-year cohorts. Relapse waslower with oral arsenic trioxide than withall-trans-renoic acid (ATRA) mainte-nance (17 vs 38 percent). Risk factors forrelapse were age, high white cell count,

and male gender.

With maintenance and salvage ATRA

since 1993 and oral arsenic trioxide since1999, 5-year OS of APL paents in rstCR [CR1] has increased signicantly from67 percent to 96 percent, said Au. Theprognosis is excellent

In fact, no APL-related deaths havebeen reported in Hong Kong since 2006 inpaents who achieved CR1, he stressed.Oral arsenic trioxide has changed the

natural history of APL in Hong Kong.APL paents treated with oral arsenic

trioxide in Hong Kong cover a broad agerange, from 6 to 86 years. No paentsstopped the therapy due to side eects,which include headache, dyspep-

sia, reversible liver funcon derange-ment and herpes zoster reacvaon.There is no QT prolongaon, which

is common with IV arsenic trioxide,said Au.


10/66


ESRD patients shifting towards home dialysis

Naomi Rodrig

More paents with end-stage renal disease(ESRD) in Hong Kong are opt-ing for home dialysis with

support from the HospitalAuthority (HA) and charita-ble donaons. Recently, 25paents have completed

a training course on homerenal replacement therapy,

aiming to improve their qual-

ity of life and lead a normal

lifestyle.

The HAs home dialysisprogram has been operat-ing since 2009, supported by a HK$ 24.2million donaon from the Hong Kong

Jockey Club Charitable Trust (HKJCCT)over 3 years. The funds were allocated

to purchase 100 sets each of automatedperitoneal dialysis (APD) machinesand nocturnal home hemodialysis

(NHHD) machines.The donaon from the HKJCCT helps

relieve the nancial burden of renal paentsin performing self-help home dialysis

treatment in a safe environment. Paentswho join the program will not only gainbeer clinical outcome but also improvetheir quality of life, said HA Chairman, Mr.Anthony Wu, who ociated at the coursegraduaon ceremony.

At present, there are around 90 renalfailure paents on APD or NHHD parci-pang in the program.

Paent training, which takes sev-eral weeks, involves preparaon and

monitoring of dialysis equipment and

supplies, placing the needle in the vascu-

lar access, keeping records of treatments,monitoring blood pressure and pulse, andcleaning the equipment and the room.

Oenmes, family members and carersalso aend the course, so they are able tohelp the paent as needed.

Home dialysis technology was rst intro-duced to local public hospitals in 2006, ena-bling paents to perform dialysis at home

every other night. NHHD paent traininghas now been extended to four public hospi-tals (Queen Mary Hospital, Queen ElizabethHospital, Princess Margaret Hospital andAlice Ho Nethersole Hospital), servingeligible paents from all HAs renal units.

To further promote the applicaonof home dialysis for ESRD paents, theHKJCCT also supported 19 dialysis nurses

who aended overseas workshops onpaent training and support.

Patient training is crucial


11/66

AnOrchestrated

Balance inType 2 Diabetes

Further information available upon request from:

Malaysia:Tel: +603 5512 [email protected]

Hong Kong:Tel: +852 2562 [email protected]

Pakistan:Tel: +92 (21) 425 [email protected]

Singapore:Tel: +65 6553 [email protected]

R E S E A R C H F O R T H E H U M A N N E E D S O F T O M O R R O W

Improves both Insulin deficiencyand Insulin resistance

Suitable as combination therapywith Metformin, Glitazones or Insulin


12/66


Epidemic warning: Fast HIV spread in Chinasgeneral population

Naomi Rodrig

An epidemiological study from theUniversity of Hong Kong (HKU) pub-lished recently in the Journal of Acquired

Immune Deciency Syndromes demon-

strated a rising prevalence of HIV-1 infec-ons among the general populaon inChinas Fujian province, coupled with an

increasing genec diversity of HIV-1 strains.The data have prompted the invesgatorsto call for enhanced surveillance to pre-

vent a looming epidemic. [JAIDS 2012; DOI:10.1097/QAI.obo13e31824f19f5]

In the province-wide study, 915,830and 2,152,658 specimens were collectedin 2006-2007 and 2008-2009, respecvely,and tested for HIV infecons by serologic

and genec analysis.The overall prevalence rate increased

signicantly in the second sampling period,from 0.064 to 0.074 percent (p=0.003). Thepercentage of homosexual transmissionsrose from 1.9 percent in 2006-2007 to 5.3percent in 2008-2009. A high frequency ofHIV-1 transmissions was related to unpro-tected heterosexual transmissions but not IV

drug use. In general, the prevalence rate hadsignicantly increased in 2008-2009 amonggeneral populaons such as voluntary blooddonors, recipients of blood transfusion,pregnant women and people undergoing

pre-operave screening (all, p 21.0 percent),

unique recombinant forms (8.1 percent) andsome minor drug-resistant variants.

Our ndings have implicaons on stra-tegic prevenon programs among general

populaons. Since the epidemic remainslargely hidden, the increased prevalence

posts a new challenge in the ght againstHIV/AIDS, said Chen.

He suggested that the data are cri-cal for Fujian to build a comprehensiveHIV prevenon program. Moreover, HIV-1surveillance and prevenon of infeconshould be immediately enhanced in low-

prevalence regions as well.We must improve surveillance and

prevenon by building up a transparentdata collecon and sharing system as wellas a reliable method to evaluate the e-cacy of our prevenve measures, addedChen. The control and eliminaon ofsexual transmission of HIV-1 among thegeneral populaon may help prevent a

larger epidemic in China and a growingpandemic worldwide.


13/66


Full disclosure or censorship?

Naomi Rodrig

The proverbial publish or perishmantra of academia has assumeda new meaning with a public debateraging over two controversial papers

describing highly pathogenic strains ofthe H5N1 flu virus that are transmissiblebetween mammals.

In two separate studies, research-

ers from the Erasmus Medical Centerin Rotterdam, The Netherlands and theUniversity of Wisconsin, Madison, USAcreated forms of the virus that can spread

between ferrets through airborne trans-mission. The papers providing experi-mental details that might allow others

to replicate the method and produce

reassortant pathogenic H5N1 virus for

humans were slated to be published inScience and Nature, respectively.

However, the US National ScienceAdvisory Board for Biosecurity (NSABB)recommended that the experimentaldetails should be redacted because of

concerns they could be used in a bio-terror attack in other words, publishand perish. The NSABB also argued thatfull publication would encourage moreresearch on those pathogenic strains,

risking accidental release.

The scientific community is divided.

The studies cannot prove whether such

mutants will or will not behave similarly

in the human population. The scientists,who take the stand that those H5N1

strains will not easily infect and spread

between humans, object to any cen-soring and want their papers publishedin full, commented Professor Kwok-

Yung Yuen, Chair of the Department ofMicrobiology, University of Hong Kong

(HKU). Whereas the more cautiouscamp would like to omit the findings that

may encourage bioterrorists to create asimilar virus with deadly potential. Both

camps have good reasons to supporttheir claims.

After weeks of deliberations, a WHOmeeting convened in late Februarydecided that the papers should be pub-lished in full.

Concern over hypothetical dual usemust be tempered with the realizationthat H5N1 viruses are continuing to

mutate and evolve in nature, said virol-ogy expert Professor Malik Peiris of the

Nature is by far the most ecient bioterrorist of all


14/66

14 April 2012 Hong Kong FocusSchool of Public Health, HKU, who was oneof the participants at the WHO meetingsupporting the decision. And experiencehas taught us that nature is by far the most

efficient bioterrorist of all.A major unanswered question ishow animal influenza viruses becomeadapted for efficient human-to-human

transmission. It has major practicalapplications for assessing their pan-

demic potential. This is the question

these two research groups have inves-

tigated. They identified mechanisms by

which avian H5N1 may acquire transmis-sibility in humans, using the ferret as ananimal model, he told Medical Tribune.

This information needs to be builtupon through further research by the

global scientific community. An increas-ing amount of animal influenza virus

surveillance data permits such informa-

tion to be applied in risk-assessment

algorithms. This research also clearlyindicates that H5N1 does indeed havepandemic potential and is one of the

more virulent pandemic candidates.

Nevertheless, the debate is still farfrom over, and the moratorium on pub-lication has been extended. The WHOdid not specify when the papers should

be published, noted Yuen. In the mean-

time, the organization is consider-ing how to handle the mutant viruses

while it comes up with strict biosafety,security and oversight provisions for

further research.


15/66


Studies reveal impact of sleep on cognitionin elderly

Chrisna Lau

Sleep disturbances may have a signi-cant impact on the aging process asstudies have shown that they are associ-

ated with increased morbidity and mortal-ity as well as impaired cognive funconingin middle-aged and older adults, accord-

ing to speakers at the 7th Internaonal

Symposium on Healthy Aging.Sleep disturbances in older adults include

reducon in slow-wave sleep and rapideye movement sleep, increase in awaken-

ings, changes in sleep architecture and cir-

cadian sleep-wake paern, as well as sleepdisorders such as insomnia and obstrucvesleep apnea [OSA], said Dr. Esther Lau ofthe Department of Psychology, University of

Hong Kong (HKU). These disturbances con-tribute to the lack of quality sleep, and areassociated with impaired cognive funcon-ing in the middle-aged and the elderly.

In an ongoing study, Lau and colleaguesfound that older adults (mean age, 76.51years) have signicantly poorer quality ofsleep than their young counterparts (mean

age, 23.3 years) as measured by sleep e-

ciency (rao of me asleep to me spent inbed), sleep duraon and sleep latency (metaken to fall asleep).

We found a correlaon between sleepand cognive funconing in older adults.For example, increased sleep latency isassociated with slower speed of process-

ing. Morning circadian preference is associ-

ated with beer basic aenon compared

with preference for aernoon or eveningacvity, she reported. Interesngly, unlike

reports in the literature, older adults in ourstudy have less dayme sleepiness thantheir young counterparts.

In another study, Lau and colleaguesfound that OSA in middle-aged and olderadults is associated with decits in process-ing speed, aenon and memory comparedwith healthy controls.

Some cognive decits in OSA paents

are reversible aer CPAP [connuous posi-ve airway pressure] treatment, said Lau. Inthose with moderate to severe OSA treatedwith CPAP, basic working memory funconswere comparable to controls, but funconsrequiring the central execuve sll showeda signicant reducon despite treatment. [JInt Neuropsychol Soc 2010;16:1077-1088]

Severe OSA, if untreated, is associated

with increased cardiovascular [CV] events.OSA is also an independent risk factor forstroke and mortality, said Professor Mary

Ip of HKUs Division of Respiratory & CricalCare Medicine. [Lancet 2005;365:1046-1053; N Engl J Med 2005;353:2034-2041;Sleep 2008;31:1079-1085]

According to Ip, it is important to treat OSAearly as excess mortality in OSA is observed

only in those younger than 50 years. [EurRespir J 2005;25:514-520] The decision ofwhether to treat elderly OSA paents or notdepends on symptoms, comorbidites and thedegree of respiratory disturbance, she sug-gested. In elderly OSA paents, there aremore hypopneas and central apneas, less oxy-gen desaturaon with events, and less symp-toms and sequelae associated with sleep

apnea. The associaon between OSA andobesity is also less strong in this populaon.


16/66


Remote device monitoring improves

patient outcomes

Increasing use of cardiovascular implant-able electronic devices (CIED) withremote-monitoring funcon has improvedtreatment outcomes, enabling earlydetecon of decompensaon and promptintervenon and reducing the burden onpaents and healthcare systems alike.

The pacemaker populaon is connu-ously expanding, with nearly half a mil-lion users reported in Europe in 2009. Assubclinical atrial brillaon [AF] and othercomplicaons are common in device usersand are associated with increased risk

of stroke and cardiac events, constant

monitoring is indicated, said Professor

Johannes Holzmeister of the University

Hospital Zurich, Switzerland.Todays CIED, including pacemak-

ers, implantable cardioverter debrilla-tors (ICD) and cardiac resynchronizaondevices (CRD), can be monitored globally.The device transmits data through a sat-

ellite to a processing center, which then

sends the report to the monitoring center/

physician via the Internet, fax or SMS.

Transmission me from reported event toalert is less than 5 minutes, he pointed

out. Although the external appliance issomewhat bulky to carry, most paents especially those who travel a lot feel

safer being constantly monitored.Remote monitoring involves automac

data acquision with unscheduled trans-missions of any prespecied alerts related to

device failure (eg, low baery or lead imped-ances out of range) and to clinical events

(eg, ischemia, arrhythmia or hemodynamic

instability). This allows benecial pre-empve intervenons that impact on dis-ease management, remarked Professor

David Hayes from the Mayo Clinic in

Rochester, USA.For example, remote monitoring has

been shown to reduce stroke risk incongesve heart failure [J Cardiovasc

Electrophysiol2009;20:1244-1251], as wellas shorten the me from onset of eventsto clinical decisions in response to arrhyth-

mias. [J Am Col Cardiol2011;57:1181-1189]According to Hayes, remote monitor-

ing of CIED is widely accepted in the USA,with more than 800,000 paents currentlyusing such systems.

Remote monitoring provides me-lier and nearly idencal informaon onCIED performance and paent statuscompared with tradional in-clinic fol-low-up. Randomized controlled trials dem-

onstrated that it reduces the need for clinic

visits, stressed Holzmeister.The TRUST trial demonstrated a 45

Internaonal Congress of Cardiology (ICC) 2012, 24-26 February 2012, Hong Kong

Naomi Rodrig reports


17/66

17 April 2012 Hong Kong FocusInternaonal Congress of Cardiology (ICC) 2012, 24-26 February 2012, Hong Kong


percent reducon in in-oce follow-upswith home monitoring vs convenonal

care, with an equal event rate. [Circulaon2010;122:325-332] Even higher reduc-ons in clinic visits were reported in theCOMPAS and REFORM trials (55 and 63percent, respecvely). [Doi: 10.1093/eur-heartj/ehr419; Computers Cardiol 2006;33:241-244]

The savings per paent-year resulngfrom reducon in clinic visits were es-

mated at 61 percent for hospital costs,

63 percent for transportaon costs and41 percent for physician me, he added.

[Computers Cardiol2006; 33:241-244]However, despite the growing posi-ve evidence, remote monitoring of CIEDsll lacks adequate reimbursement, saidHolzmeister. Addional reasons for theslow implementaon may be related topaent preference for face-to-face con-sultaons and reluctance of private prac-oners whose income might be aected,

he speculated.

The Essential

Medical Reference

The Complete Solution

100%pure knowledge

MIMS in Print, Online, Email, Mobile or integrated clinic software


18/66


Role of echocardiography in heart failure

Echocardiography is an easily availabletechnology with a major role in the

diagnosis and management of heart fail-

ure (HF), according to Professor Jing-PingSun of the Emory University School ofMedicine, Atlanta, USA.

When HF is clinically suspected, echo-cardiography is the single most important

technique, essenal in the diagnosis and

idencaon of underlying eology of HF,she said. In about half of the paents even-tually conrmed to have HF, it demonstratesa major structural and/or funconal abnor-mality, such as systolic HF, severe valvularheart disease, congenital heart disease

or cardiomyopathies.

In the remaining 50 percent of paentswho have HF with preserved ejecon frac-

on (EF), the abnormalies may be subtleon two-dimenonal echocardiography.To ascertain the underlying eology ofHF, addional invesgaons are required,such as myocardial or ssue Doppler imag-ing, Sun suggested. Tissue Doppler imag-

ing of the septal mitral annulus is helpful

in dierenang pseudo-normal from truenormal mitral ow velocies, and dieren-

ang constricve pericardis from myo-cardial diseases.

According to Sun, it is also importantto consider right HF, pulmonary pro-cess and non-cardiopulmonary process

if diastolic funcon evaluaon showsrelavely normal lling pressure at rest.

Another important condion to con-sider is exercise-induced increased ll-

ing pressure that may have led to thepaents symptoms of shortness of

breath. Therefore, we need to assess ll-

ing pressure at rest and with exercise, shesuggested.

New developments in echocardiogra-phy now allow objecve quancaon ofregional and global myocardial funcon.Regional deformaon (strain, rotaon andtwist) and deformaon rate (strain-rate)can be calculated non-invasively in bothventricles.

Echocardiography is also helpful in select-ing the opmal therapy for HF paents. Forexample, it can help idenfy paents whorequire cardiac resynchronizaon therapyaccording to established criteria, and adjustthe opmal atrioventricular delay me,said Sun.

Furthermore, echocardiography is use-

ful for monitoring treatment response and

predicng paent prognosis, as well as anevaluaon tool in HF trials.

Internaonal Congress of Cardiology (ICC) 2012, 24-26 February 2012, Hong Kong



19/66

Reference:1. Smith RD, Yokoyama H, Averill DB et al. Reversal of vascular hypertrophy in hypertensive pati ents through blockade of angiotensin II receptors. JASH 2008; 2 (3) :165-172.

OlmetecAchieves near normal BP levels in

hypertensive patients1

Provides more complete end organprotection with additional data on

Reversal of vascular remodeling1

:Bringing the measured parameter

to values similar to normotensive

controls

Results independent of themagnitude in BP reduction

U-TURN away from

Vascular Remodeling

VitalBase/HK/A

R008/110426

OLM11008P


20/66


Peer counseling helps young smokers quit

Chrisna Lau

Peer counseling is eecve in youngsmokers with depressive symptomswho nd it harder to kick the habit, accord-ing to a study by the University of HongKong (HKU).

Depressive symptoms aect 47 percentof smokers who received service at HKUsYouth Quitline between March 2006 andMay 2011. Youth smokers with depressivesymptoms had a higher level of niconedependence, said Professor Sophia Chan

of the School of Nursing, who reportedthe ndings at the opening ceremony ofthe Youth Quitline Center.

Despite similar levels of intenon toquit, youth smokers with depressive symp-

toms perceived higher diculty and lowercondence in kicking the habit than thosewithout depressive symptoms. At 6-monthfollow-up, the quit rate was 10.6 percent

for those with notable depressive symp-toms, vs 32.3 percent for those without

depressive symptoms.

It also took longer for those with nota-

ble depressive symptoms to iniate a quitaempt (average, 15 days post telephone

counseling). While 45 percent of youthsmokers had made a quit aempt aer tel-ephone counseling, those with depressive

symptoms were more prone to relapse as

only 18 percent were able to abstain fromsmoking for at least 7 days (vs 35 percent

for those without depressive symptoms).

Peer counseling provided by trainedstudents of similar age reduced the num-

ber of youth smokers with depressivesymptoms by 7.2 percent aer 6 months,said Chan.

Supported by funding from the TobaccoControl Oce of the Department of Health,the new Youth Quitline Center now pro-vides more intensive telephone counseling

for callers. A web-based interacve cessa-on service will be launched by the end of

2012 in collaboraon with Quit Victoria inAustralia, Chan added.


21/66


What medical information do doctors seek?

Naomi Rodrig

Arecent survey conducted by MIMS.comindicated that Asian doctors preferauthoritave, expert-authored/reviewedclinical informaon over less formal sourcessuch as peer discussion groups. [MedicalInformaon & Professional Networking

HCP Survey, Jan 2012]The survey included over 1,700 phy-

sicians and healthcare professionals

from several Asian countries. Amongthe respondents, 34 percent ranked

drug informaon as their top area ofprofessional interest, followed by CME(Connuing Medical Educaon, 30 per-cent) and diagnosc/paent informaon

(25 percent). Only 11 percent of respond-ents ranked peer-to-peer interacon as

their top priority.

The majority of doctors consider highlycredible informaon from clinical guide-lines and expert communicaons (ie, con-ferences, symposia and peer-reviewed

journals) as the preferred source of medi-cal updates.

In the area of drug informaon, 63 per-

cent cited high interest in expert over-views, best pracce sharing, and clinicalexperience in drug usage. Peer discussionsand workshops on drug usage and paentoutcomes ranked second at 35 percent,

while only 19 percent were interested inlearning about o-label drug indicaons.

MIMS and MIMS.com are part of a com-

prehensive drug informaon system from

UBM Medica, a healthcare media companyand publisher ofMedical Tribune.


22/66


23/66


Hong Kong Events

Le Atrial Appendage Closure

Workshop Hong Kong 2012

Division of Cardiology and Instute ofVascular Medicine, CUHK27/4-28/4Tel: (852) 2647 6639Fax: (852) 2144 5343E-mail: [email protected]/laa/

20th Annual Scienc Congress

Hong Kong College of Cardiology4/5-6/5

Info: Ms. Lynn Lam / Ms. Queenie WongTel: (852) 2911 7902 / 2911 7923Fax: (852) 2893 0804 / 2838 7114E-mail: [email protected] /[email protected]/scienccongress.php

Hospital Authority Convenon 20127/5-8/5Info: Ms. Cynthia KongTel: (852) 2300 6557Fax: (852) 2890 7726E-mail: [email protected]/haconvenon/hac2012

17th Hong Kong Medical Forum

Department of Medicine, HKU; QueenMary Hospital12/5-13/5Tel: (852) 2255 4607Fax: (852) 2855 1143www.hku.hk/medicine/hkmf

9th Hong Kong Internaonal Orthopedic

Forum Orthopedics and Pain

Department of Orthopedics &Traumatology, HKU

26/5-27/5

Info: Ms. Chang

Tel: (852) 2255 4257www.hku.hk/ortho/forum2012

Advanced Laparoscopic Urology

Workshop

Department of Surgery; Pamela YoudeNethersole Eastern Hospital; Hong KongUrological Associaon28/5

Tel: (852) 2595 6362Fax: (852) 2505 7101E-mail: [email protected]/mastc

Advances in Medicine 2012

Department of Medicine & Therapeucs,CUHK2/6-3/6

Info: Ms. Priscilla Chu / Ms. Flora LoTel: (852) 2632 3593 / 2632 3307Fax: (852) 2637 3852E-mail: [email protected] /[email protected]/AIM2012/index.htm

Hong Kong Primary Care Conference

Hong Kong College of Family Physicians2/6-3/6

Info: Ms. Crystal Yung / Ms. Priscilla LiTel: (852) 2861 0220Fax: (852) 2866 0981E-mail: [email protected]/


24/66

24 April 2012 Hong Kong FocusHong Kong Events

Internaonal Digesve Disease (IDD)

Forum

Instute of Digesve Disease, CUHK9/6-10/6Info: Swire TravelTel: (852) 3151 8900Fax: (852) 2590 0099E-mail: [email protected]

Annual Scienc Meeng 2012

Hong Kong Society of Dermatology andVenereology

10/6Info: UBM Medica Pacic LimitedTel: (852) 2155 8557 / 2116 4348Fax: (852) 2559 6910E-mail: [email protected]

2nd IDKD Intensive Course in Hong

Kong Diseases of the Abdomen andPelvis

16/6-19/6Info: Swire Travel LimitedTel: 852 (0) 315 188 19Fax: 852 (0) 315 463 24E-mail: [email protected]

12th Asian Conference on Clinical

Pharmacy

School of Pharmacy, CUHK7/7-9/7Info: UBM Medica Pacic LimitedTel: (852) 2155 8557 / 3153 4374Fax: (852) 2559 6910E-mail: [email protected]

2012 Conference of Asia Oceania

Research Organizaon on GenitalInfecon and Neoplasia (AOGIN 2012)

Department of Obstetrics andGynecology, HKU13/7-15/7Info: PC Tour and TravelTel: (852) 2734 3315Fax: (852) 2367 3375E-mail: [email protected]

www.ogshk.org/2011/AOGIN_2012.pdf

Annual Scienc Meeng

Hong Kong Instute of Musculoskeletal

Medicine

21/7-22/7Info: UBM Medica Pacic LimitedTel: (852) 2155 8557 / 3153 4374Fax: (852) 2559 6910

E-mail: [email protected]

www.neuropainhk.orgGet the latest recommendations on the diagnosis and treatment o

various neuropathic pain states rom the frst Hong Kong Web sitededicated to education on neuropathic pain.


25/66


26/66

26 April 2012 News

Contaminated TCM products cause liver damage

Radha Chitale

Contaminants in traditional Chinesemedicines (TCM) can cause seri-ous, sometimes fatal, liver failure,

according to research presented at the

22nd Conference of the Asian PacificAssociation for the Study of the Liver(APASL) held in Taipei recently.

A recent survey of 26 patients admit-

ted to National University Hospital(NUH) Singapore with acute liver fail-ure found that 11 (42.3 percent) of thecases were associated with the use of

TCM products. Four of these patients

died.

Drug-induced liver injury has a differ-ent etiology and severity profile in Asiacompared with the West and TCMs were

the most commonly implicated drugs inour series, said lead researcher Dr. LimSeng Gee, chief of gastroenterology at

NUH. Lim added that the results wereunique to Asia, where TCMs are widelyavailable, and that data on herbal med-icines are under-reported or poorly

reported in general.

Previous evaluations of TCM medica-

tions which may have been ingested bypatients admitted to NUH with drug-induced liver injury liver showed thatup to 30 percent were adulterated with

pharmacologic agents such as corticos-

teroids, beberine, metformin, phenylb-utazone, paracetamol and amidopyrine.

Lim pointed out that a natural herbis not necessarily safe or effective, and

that while it may not be classified as adrug it can still have a pharmacologic

effect that can be toxic.In order to reduce the risk of [liver

injury], we should discuss [TCM] use inindividual patients, recommend non-

use or safe use of reputable products toreduce dose escalation, caution against

drug-drug interactions, and monitor

patients with hepatitis, he said. The

risk of herbal hepatotoxicity and adverse

events of herbs seems to outweigh thebenefits.

Some TCM products are contaminated withpharmacologic ingredients which can cause livertoxicity.


27/66

27 April 2012 News

Spinal cord monitoring imperativeduring surgery

Susie Sell

The spinal cord should be monitored dur-ing surgery to prevent post-operave-onset paralysis and loss of muscle funcon,an updated guideline by the AmericanAcademy of Neurology (AAN) recommends.

The guideline said there is strong evi-

dence to show intraoperave monitoring

(IOM) of the spinal cord during spinal sur-gery or certain chest surgeries can alert sur-

geons and anesthesiologists of problemsbefore damage occurs.

A panel of experts at the AAN reviewed12 research papers to determine whetherIOM with somatosensory and transcranial

electrical motor evoked potenals (EPs)can predict paralysis related to the surgery.

[Neurology2012; 78: 585-589]They found the studies were consistent

in showing all paraparesis, paraplegia, and

quadriplegia events occurred in paentswith EP change.

In one set of studies, 16-40 percent ofIOM paents with EP changes developedpost-operave-onset paraparesis, paraple-gia or quadriplegia, but no adverse out-

come events occurred in paents withoutan EP change.

The AAN guideline, which was developedwith the American Clinical NeurophysiologySociety, recommends surgeons and other

members of the operang team shouldbe alerted to the increased risk of severeadverse neurologic outcomes in paentswith important IOM changes.

Paraparesis, paraplegia and quadriple-gia are potenal serious complicaons of

surgeries where the spinal cord is at risk,

said lead author Dr. Marc Nuwer, medicaldirector of the University of California, LosAngeles and a fellow of the AAN.

Monitoring can help prevent damage byidenfying problems early enough to allowfor intervenons. If intraoperave monitor-

ing raises warnings, surgeons and anesthe-siologists can modify the surgery to reduce

the risk of these complicaons, he said.The expert panel said anesthesiologists

and surgeons can intervene in a variety of

ways when IOM raises warnings, includ-

ing adjusng retractors, reimplanng orunclamping arteries or minimizing the

remaining poron of the surgery. Surgeons

also have the opportunity to check a wake-up test in some paents, it said.

The panel said the literature review sup-

ports the performance of spinal cord moni-

toring under the supervision of a clinical

neurophysiologist experienced with IOM.The studies do not support IOM conducted

by technicians alone or by an automateddevice, it added.

The best way to treat paralysis is to pre-vent it in the rst place, said Nuwer.

Surgery can place a patients spinal cord at

risk of serious complications including post-operative paralysis and paraparesis.


28/66


29/66

29 April 2012 News

Smartphone technology being looked at fortreating substance abuse, PTSD

Susie Sell

Smartphones could be used to help treatpaents with a history of substanceabuse and post-traumac stress disorder(PTSD), according to a US-based study.

Researchers at the University ofMassachuses Medical School, Worcester,Massachuses, US, are developing a wrist-

band that can idenfy and transmit drugcravings to a smartphone, which responds

with tailored intervenons aimed to pre-vent drug use. [J Medical Toxicology2012DOI: 10.1007/s13181-011-0200-4]

The wristband could be used to makeintervenons for substance abusers moreeecve outside the clinical environment,the researchers said.

The wristband measures physiologicalindicators of stress, such as body moon,skin temperature, electrical acvity of theskin and heart rate.

This informaon is wirelessly trans-

mied to a smartphone, where sowareapplicaons process the data. If the so-ware detects an increase in stress level, it

asks the user to input informaon abouttheir perceived level of stress, drug crav-

ings and current acvies.The goal is to use this data to create an

algorithm that can predict real-me drugcravings and use a smartphone to deliver

personalized, mul-media drug prevenonintervenons at the moment of greatest

need, the researchers said.

The technology was tested on a focus

group of seven male war veterans, aged

between 27 and 55 years old, who wereundergoing residenal treatment for sub-

stance abuse and PTSD.The group highlighted a number of

potenal limitaons of the technologyin its current form. It said the wristband

was acceptable for research purposes but

wearing it outside of a residenal drugtreatment center might aract unwantedaenon.

The heightened visibility created apotenal for sgmazaon, the research-ers said.

The focus group said a more robustand less sgmazing version would benecessary before the device could be

worn in public, suggesng the develop-ment of a band that has the appearance

The technology could be the next big thing for

treatment across Asia


30/66

30 April 2012 News

of a wristwatch or a band that is worn onthe ankle.

Adjunct Associate Professor MunidasaWinslow from the department of psy-

chological medicine at the NationalUniversity of Singapore Yong Loo LinSchool of Medicine said the technology

could be the next big thing for treat-ment across Asia.

I think this could happen very fast as

we are quick adopters of new technologies

and methods for treatment, he said. The

advantages are prey good as most peo-

ple keep the smartphone or 3G technologywith them most of the me, unlike therapy

sessions. And the cyber program can pickup things faster and more remotely than a

human can.

But Winslow stressed the technology

should not substute tradional treatmentapproaches.I think it would be best if tagged onto

the more established forms of therapywhich have already been tried and tested,such as 12-step therapies, individual andgroup counseling for substance abuse andeye movement desensizaon and repro-cessing (EMDR), and other cognive ther-

apies for post-traumac stress disorder,he said.

From the research bench to your patients bedside JPOG raises the

quality of life of women and children in Asia. Pick up a copy today and

start earning CME points.

For further details, visit www.jpog.com today.

JPOG isNOWCME-Accredited...

in Hong Kong, Indonesia,

Malaysia and Singapore

For over 35 years, JPOG has been the only regional,

peer-reviewed journal of paediatrics, obstetrics and

gynaecology in Asia. The bimonthly journal is proud to

announce its CME-accreditation in the following Asian

countries: HONG KONG, INDONESIA,

MALAYSIA and SINGAPORE.


31/66

31 April 2012 News

Experts discuss pneumococcal diseaseburden in Asia

Radha Chitale

Infecous disease experts highlightedthe need for increased awareness ofpneumococcal disease and the eec-ve vaccines available against them dur-ing the 2012 Asia Pneumococcal DiseaseConference, held recently in Hong Kong.

In parcular, the latest pneumococcal con-

jugate vaccine, eecve against 13 pneumo-coccal bacteria serotypes (PCV13), includesprotecon against serotype 19A infecons,an emerging serotype that experts say is theunderlying factor in the rise of pneumococ-

cal infecons in children under age 5 and isassociated with anbioc resistance.

Pneumococcal disease is responsible forup to 1 million deaths among young children

under age 5 around the world, according tothe World Health Organizaon. About one-quarter of these infecons are due to sero-type 19A, and are increasing in prevalence.[Diagn Microbiol Infect Dis 2008;61:256-263;Emerg Infect Dis 2008;14:275-281]

It is indeed very sad and frustrang tosee that so many young children and fami-

lies are suering from pneumococcal dis-

ease especially when it can be prevented,said Professor Ron Dagan, director of

the Pediatric Infecous Disease Unit atthe Department of Pediatrics at Soroka

University in Beer-Sheva, Israel.PCV13, which became available in Asia in

2010 and protects against six more serotypesthan its predecessor, PCV7, decreased inva-sive pneumococcal disease by 36 percent fol-

lowing its introducon among children in theUS compared to the 3 years prior, according

to the results of a prospecve surveillancestudy presented at the Annual Meeng ofthe Infecous Diseases Society of America in2011.

High-level resistance to anbiocs also

decreased during the trial period, 2010 to2011.

Dagan noted that children are not the

only segment of the populaon at risk forcomplicaons of pneumococcal disease.Pneumococcal pneumonia is common

among adults and it can be communityacquired, leading to signicant morbidityand mortality, parcularly in Asia. [Clin Infect

Dis2000;31:347-382; Int J Anmicrob Agents2011;38:108-117]

With the rise in aging populaon in mostAsian countries, [pneumococcal disease inadults] is becoming a growing concern itcan have devastang eects at the societaland family level and thats why its crical forhealthcare professionals to work with par-

ents and government authories on advanc-

ing the means to beer protect them fromthe disease, Dagan said.

Children are not the only ones at risk ofpneumococcal disease the disease is alsocommon among adults.


32/66

32 April 2012 News

Strength of intestinal barrier key incancer prevention

Susie Sell

Astrong intesnal barrier could helpprevent cancers forming in the rest ofthe body and inammatory bowel disease,preclinical research suggests.

A study in mice has shown that the hor-mone receptor guanylyl cyclase C (GC-C)

plays a key role in strengthening the intes-

nal barrier. [PLos ONE2012. DOI:10.1371/journal.pone.0031686]

Mice decient in GC-C and mice withacvated GC-C were administered dextransulfate sodium (DSS) in drinking water for

7 days to disrupt the epithelial barrier andinduce colis. Severity of colis was ana-lyzed by body weight and survival rate.

The results showed that GC-C-decient

mice had DSS-induced colis with a 3-foldgreater severity compared with GC-C-

acvated mice.DSS colis was also associated with >80

percent mortality in GC-C-decient mice,as compared with GC-C-acvated mice,which exhibited 100 percent survival.

The researchers found the weakened

intesnal barrier caused tumors in the liv-

ers, lungs and lymph nodes in 50 percentof GC-C-decient mice, but in only 10 per-cent of GC-C-acvated mice.

If the intesnal barrier breaks down itbecomes a portal for stu in the outsideworld to leak into the inside world. When

these worlds collide it can cause diseases

like inammaon and cancer, said leadresearcher Dr. Sco Waldman, chairman

of the Department of Pharmacology andExperimental Therapeucs at Thomas

Jeerson University in Philadelphia,Pennsylvania, US.

A weakened intesnal barrier has beenlinked to diseases such as asthma, diabe-tes and food allergies.

Waldmans team had previously idenedGC-C as a tumor suppressor and biomarkerthat reveals occult metastases in lymph

nodes. But this latest study provides freshevidence that GC-C plays a role in intesnalbarrier integrity, the researchers said.

Waldman said the study sets the founda-

on for future research into the role of GC-C inprevenng and treang inammatory boweldisease and cancer. A new drug containingGC-C is set to be released, but its intendedprescribed purpose is to treat conspaon.

Weve shown that when you pull awayGC-C in animals you disrupt the intesnal bar-rier, pung them at risk for geng inam-matory bowel disease and cancer. And whenyou treat them with hormones that acvateGC-C it helps strengthen the integrity of the

intesnal barrier, Waldman said.If you want to prevent inammaon or

cancer in humans then we need to start think-

ing about feeding people hormones that ac-vate GC-C to ghten up the barrier.


33/66

THANK YOU

FOR YOUR

CONFIDENCE IN

FOR MORETHAN 20 YEARS

* Thailand, Malaysia, Hong Kong & Singapore

** Defined Daily Dosages

Further information availableupon request from:

Hong KongTel: +852 2562 6276

YOUR TRUST IN NIDOL

BENEFITS YOUR PATIENTS

Available:

in more than

56 countries

Treated:

over 500 million

patients

World Wide:

> 7.7 billion Defined

Daily Dosages

South-East

Asia:*

> 22.5 million DDDs**

in 2007 for Nidol

nimesulide

R E S E A R C H F O R T H E H U M A N N E E D S O F T O M O R R O W

[email protected]


34/66

34 April 2012 News

Overeating doubles risk of memory loss

Elvira Manzano

Overeang appears to be associatedwith an increased risk of mild cogniveimpairment (MCI) in the elderly, according

to a leading neurologist.

Dr. Yonas E. Geda, from the Mayo

Clinic, Scosdale, Arizona, US, was refer-ring to the results of her own study which

found that people who consumed more

than 2,142.5 kilocalories a day had nearlytwice the risk of developing memory loss

compared with those who ate fewer than

1,526 kilocalories a day.We observed a dose-response paern

which simply means that the higher the

amount of calories consumed each day,

the higher the risk of MCI, said Geda,

a member of the American Academy of

Neurology (AAN).MCI is an intermediate stage between

the expected cognive decline of normalaging and the more pronounced decline

of demena. People with MCI are at anincreased risk of later developing demen-

a, including Alzheimers disease, andmay experience problems with memory,language, thinking and judgment that are

greater than typical age-related changes.In this case-controlled study, Geda and

colleagues surveyed a random sample of

1,233 people aged 70 to 89 parcipat-ing in a populaon-based cohort study inOlmstead County, Minnesota, US, abouttheir daily caloric consumpon.

Volunteers 1,070 without demen-a and 163 with MCI were divided into

three groups based on their daily caloricintake. The rst group consumed between

600 and 1,526 calories and was used as areference group. The second group con-

sumed between 1,526 and 2,143 calories,while the third group consumed between

2,142.5 and 6,000 calories.Compared with the rst group, the sec-

ond group had a higher risk of MCI, but theresults did not reach any stascal signi-cance (odds rao [OR] 1.05, 95% CI 0.63 to1.77). Interesngly, the third group had thegreatest risk of developing MCI (OR 2.41,95% CI 1.51 to 3.86).

The results did not change even aer

adjusng for other factors that could aectrisk of memory loss such as history of

stroke, diabetes and educaon.Cung calories and eang foods that

make up a healthy diet may be a simplerway to prevent memory loss as we age,

Geda concluded.

The full study results are expected tobe presented at the annual meeng of the

AAN being held in New Orleans, Louisiana,US, in April.

People who consumed over 2,142.5 kilocalories/day had almost twice the risk of developingmemory loss than those who ate less than 1,526kilocalories/day.


35/66

35 April 2012 News

Rapid memory loss linked to fatal strokeElvira Manzano

Asharp decline in memory is associatedwith worse stroke outcomes, accord-

ing to a recent US study.We are most surprised that people

who died aer strokes had sharp mem-ory declines [in the] years before strokeonset, said Ms. Qunyi Wang, lead authorof the study and a graduate student at the

Harvard University School of Public Health

in Boston, Massachuses, US.

Dr. M. Maria Glymour, co-author of the

study from the same instuon, said thosewho died from stroke may have worse

underlying disease prior to stroke, whichsuggests that early disease is accumulangand that something is happening to these

people before they are diagnosed withclinical stroke.

Commenng on the study, AssociateProfessor N.V. Ramani, a senior consultantin the division of neurology at NaonalUniversity Hospital, Singapore, said: Its

an interesng study showing that thosewith lower memory funcon had a higherstroke risk and those who had higher

rates of memory decline had higher post-

stroke mortality.

While he described the results asintriguing, he said these will not impact

directly on clinical pracce. What weneed are eecve treatments that reduce

stroke and stroke-mortality among thosewith lower memory funcon.

The 10-year study involved more than11,800 individuals aged 50 and older with

no history of stroke at baseline. To assessdeclining memory funcon, they under-went word-recall tests every 2 years. For

those whose memory loss was too severe to

use the word lists, researchers interviewed

spouses or other caregivers. [InternaonalStroke Conference 2012; Abstract 31]

During the study period, 1,800 sueredstrokes and 364 died before their next

memory test. While memory declined rap-

idly each year for stroke survivors prior to

stroke onset, it dropped even faster for

those who did not survive the stroke. By

comparison, memory decline for individu-als who did not have a stroke occurs at a

much slower pace.

On average, the memory scores of peo-

ple who did not have a stroke dropped

0.078 points a year. Those who had a strokebut survived scored 0.137 points lowereach year, while those who died from the

event dropped 0.205 points a year.

Contrary to what the findings suggest,severe memory loss is not a strong pre-

dictor of future fatal stroke, said Ramani,

a known stroke leader. Those with

severe memory loss tend to succumbto complications of a bedbound state.Stroke may cause cognitive impairment

without memory loss. Cognitive impair-

ment after stroke is a well-known and

important clinical entity for which weneed better treatments.

We are most surprised that people who died aer strokes

had sharp memory declines [in the] years

before stroke onset


36/66

NTRODUCING THE FIRST ORAL,ONCE-DAILY DIRECT FACTOR Xa INHIBITOR

: Uniquely Targeted Action in Preventing Clots

NTRODUCING THE FIRST ORAL,ONCE-DAILY DIRECT FACT

: Uniquely Targeted Action in Pre

6 Xarelto possess the criteriaof ideal anticoagulant

t Convenience of one 10-mg tablet,

once daily1

t No dose adjustments with regard

to age, gender, body weight, or

ethnicity1,2,3,4

t No requirement for routine

coagulation monitoring1

t No dietary restrictions5

Bayer HealthCare LimitedNos. 801-808, 8/F Shui On Centre,

6-8 Harbour Road, Wanchai, Hong Kong

Tel: (852) 2814 7337 Fax: (852) 3526 4755

Abbreviated SmPCXarelto 10 mg film-coated tablets.Composition:Active ingredient: 10 mg rivaroxaban. Indication: Prevention of venous thromboembolism (VTE) in adultpatients undergoing elective hip or knee replacement surgery. Contraindications: Hypersensitivity to the activesubstance or to any of the excipients; clinically significant active bleeding; hepatic disease associated with c oagulopathyand clinically relevant bleeding risk, pregnancy and lactation. Warnings and Precautions:Treatment with rivaroxaban isnot recommended in patients: - concomitantly treated systemically with strong concurrent CYP3A4- and P-gp-inhibitors,

ie, azole-antimycotics (such as ketoconazole, itraconazole, voriconazole and posaconazole) or HIV protease inhibitors(eg, ritonavir), - with severe renal impairment (creatinine clearance


37/66

37 April 2012 Conference Coverage20th Regional Conference of Dermatology, 20-23 February, Manila, Philippines

Re-emerging skin infections presentmajor challenge

Dr. Yves St. James Aquino

Epstein-Barr virus (EBV), varicella zostervirus (VZV) and atypical mycobacteriumare part of a growing list of re-emerging skin

infecons caused by organisms that havebeen relavely controlled in the past, butwhich have recently been reacvated due to

changes in the environment, the organism orthe host.

We have been encroaching so muchupon our environment because our popula-on is growing, and we try to cut more trees,and we get exposed to weird insects that har-bor weird organisms. And later we developdiseases, said Dr. Raul Destura, infec-

ous disease specialist and director of the

Naonal Instute of Molecular Biology andBiotechnology under the Naonal Instutesof Health-University of the Philippines,Manila, Philippines.

Destura explained that these factors cancontribute to either increased host suscep-bility or increased disease transmission.

The re-emergence of EBV, a human herpesvirus that infects human mucosal epithelial

cells and B lymphocytes, has been aributedto the increasing trend of immunosuppres-

sion in paents, such as those with cancer orautoimmune diseases, said Destura.

Reducing immunosuppressive therapy is

considered as part of treatment, as seen in

reported series of cases involving paentswith methotrexate-associated EBV. In thisparcular series, just removing methotrex-

ate or disconnuing it actually resolved EBV-associated cutaneous lesions, explained

Destura.

For atypical mycobacterium infecons,which can present as abscesses, ulcera-ons or lymphangis, emergence may be aresult of immunosuppression and increase

in leisure acvies that involve skin-to-skincontact, according to Destura. Atypical myco-bacteria are becoming more virulent espe-

cially for skin and so ssue infecons.The medicaons against atypical myco-

bacteria may include a combinaon ofrifampicin, quinolones, doxycycline and/orerythromycin. There is sll no standard dura-on of treatment, but most of the me its 6to 8 weeks, said Destura.

Known commonly to cause chickenpox inchildren and herpes zoster mainly in adults,

VSV may manifest as painful vesicular erup-ons with erythematous base in one to threedermatomal lines, facial weakness, post-her-

pec neuralgia, among others.Besides immunosuppresion and an aging

populaon, another potenal contributor tothe increase in incidence of VSV is the emer-gence of new manifestaons associated withthe disease. Destura added that recently,

reacvated zoster presents with predomi-nance of cutaneous pain without associated

rash, in addion to neurologic manifesta-ons, such as myelis, meningoradiculis,encephalomyelis and ventriculis.

The clinical dermatologist remains an

important player in the detecon of theseagents. And as the world gets smaller andsmaller, the pracce of medicine needs to

become more connecve and collaborave,concluded Destura.


38/66

38 April 2012 Conference Coverage20th Regional Conference of Dermatology, 20-23 February, Manila, Philippines

Psoriasis studies show link with stress

Dr. Yves St. James Aquino

Studies show that social aggressors andemoonal stress can worsen symptomsof psoriasis, providing further evidence

for the existence of a brain-skin axis, saidDr. Christopher Griths, foundaon pro-fessor of dermatology in the University ofManchester, Manchester, UK.

Griths and other members of theDermatological Sciences Research Group

within the School of Translaonal Medicinein Manchester are studying the two-direc-

onal relaonship between psychologicalstress and skin disease.

To understand the mechanism behind thepsychosocial disability in psoriasis, one of therst studies performed by the group involved

an automac vigilance test. This psycholog-ical test was done by asking subjects to viewa computer screen that showed words in

dierent colors. The subjects were asked toidenfy the color and not to read the word.The researchers then measured the me ittook for the subjects to idenfy the coloraer the word was shown. The more rele-vant the word is to that subject, the longer it

takes for that subject to say the color.Condion-relevant words such as

embarrassed, ridicule and itchy wereused, as well as neutral ones like tableand tree. Results show that subjects withpsoriasis take much longer than normal

volunteers when the words are relevant

to their condion, while there is no signi-cant dierence in neutral words.

What that means is that peoplewith psoriasis are scanning their local

environment looking for cues about themhaving the disease. They misinterpret nor-mal, everyday events as the fact theyve

got psoriasis, explained Griths.Another study demonstrated how worry

makes paents with psoriasis less likely torespond to psoralen + ultraviolet A (PUVA)therapy. Griths team assessed the sever-ity of psoriasis, psychological distress, alcohol

consumpon, skin type in 112 paents be forestarng PUVA therapy. The group used thePenn State Worry Quesonnaire to discrimi-nate people who were low-worry (65 percent)

and those who were high-worry (35 percent).

The researchers found that high-level

worriers took 1.8 mes longer to respondto PUVA compared with the low-level wor-riers. And even if they did respond, it took

them more treatments to respond. Sohigh-worry or high-anxiety has a negaveeect on response, said Griths.

In order to promote a more holiscapproach to psoriasis treatment, Grithsand his colleagues invesgated how cognivebehavioral therapy (CBT) may help alleviatesymptoms. The CBT involved group therapy,

teaching about psoriasis, stress reducon,

and behavioral techniques to manage mis-interpretaon of other peoples reacons.Using the Psoriasis Area and Severity Index(PASI), they compared paents who receivedregular treatments and CBT with paentswho were receiving regular treatments alone.

Aer 6 weeks, those who had behavioraltherapy had a signicantly improved PASI;and aer 6 months, the same group had

even beer improvement in dealing withemoonal stress, said Griths.


39/66


40/66

40 April 2012 Conference Coverage

Personal Perspectives

I think its important for dermatologists to share theirinformaon ... Its important for us to be familiar with whats

brewing, or whats becoming more and more innovave in Asia.

Dr. Anthony Paul Bewley

Dermatologist, Barts and The London NHS Trust

Whipps Cross University Hospital NHS Trust, London, UK

We share similar dermatologic diseases, but because of our

different locations and cultures, our approaches may be

different. Its important that we get together once in a while

and share what we know about skin diseases ... There are many

ideas here in this convention and hopefully it does improve

patient care.

Dr. Belen Dotas

Dermatologist, University of the Philippines-Philippine General

Hospital, St. Lukes Medical Center

Manila, Philippines

One of the interesng topics I think is STD [sexuallytransmied diseases], because in my country there are so

many cases. The informaon is something I can take home.

Dr. Dewi Marni

Dermatologist, Fatmawa Hospital, Jakarta, Indonesia

A lot of the topics are informative. Basically, the lectures werediseases that we commonly see in the out-patient department.Some are rare and worthy as case reports but are still very

must-know.

Dr. Joahnna Villena

Resident-in-training

University of the Philippines-Philippine General Hospital,Manila, Philippines

20th Regional Conference of Dermatology, 20-23 February, Manila, Philippines


41/66

41 April 2012 Conference Coverage22nd Conference of the Asian Pacific Association for the Study of the Liver, 16-19 February, Taipei

Elvira Manzano

New guidelines released by the AsiaPacic Associaon for the Study ofthe Liver (APASL) now also recommendtenofovir disoproxil fumarate (TDF), anucleos(t)ide analogue (NUC), as a rst-line treatment opon for paents withchronic hepas B.

TDF joins entecavir (ETV) and peginter-feron (peg-IFN) as a recommended rst-line choice in treatment-naive paentswith this disease. Lamivudine (LAM), tel-vibudine (LdT) or adefovir (ADV) can beused as second-line agents based on levelB evidence, said Professor Yun-Fan Liaw,chairman of the guidelines review panel

and head of the Liver Research Unit, Chang

Gung University and Memorial Hospital inTaipei, Taiwan.

TDF or ETV is the preferred NUC. TDFor ETV is also the treatment of choice forpaents with impending or obvious hepacdecompensaon, he added. Interferon-based therapy is contraindicated in thisseng because of the risk of IFN-inducedhepas ares and serious infecon.

LAM has fallen out as a rst-line therapyfor hepac decompensaon due to high

rate of resistance associated with its long-term use. By contrast, TDF and ETV areassociated with the lowest rate of resist-

ance in treatment-naive paents.The full version of the new guidelines

is expected to be published in HepatologyInternaonal, the ocial journal of APASL.

First-me recommendaons includean-viral therapy in paents with hepato-

cellular carcinoma, use of biologic agents(rituximab, etanercept, etc) alone or in

APASL Hep B guidelines Tenofovir added asfirst-line option


42/66


combinaon with corcosteroid containingregimens in HBsAg-negave paents, andprevenon of mother-newborn transmis-

sion. LdT or TDF is preferred in pregnantwomen needing treatment, Liaw said.Active anti-retroviral therapy (ART)

containing TDF plus emtricitabine(FTC)/LAM is preferred for HBV patients co-infected with HIV. ADV or peg-INF can beconsidered if CD4 count is >500 and ARTis not warranted.

Paents with advanced brosis or cir-

rhosis and those with ALT of twice theupper limit normal (ULN) and an HBV-DNAof 20,000 IU/mL [if HBeAg posive] or2,000 IU/mL [if HBeAg-negave] shouldbe considered for treatment. Paents withhepac decompensaon need immedi-ate treatment. Otherwise, 3 to 6 months

observaon is reasonable, said Liaw.The new guidelines also suggest

monitoring of alanine aminotransferase

(ALT) and HBV markers (HBeAg, HBV-DNA)for a minimum of 3 months during therapy;

monthly for 3 months, and every quarterthereaer for 1 year, aer therapy. In IFNtherapy, monitoring of blood cell countand adverse eects is mandatory.

The World Health Organization esti-mates that 600,000 people die every

year from hepatitis B infection. The chal-

lenge for clinicians is to identify patients

at risk, offer treatment and avoid resist-

ance to prevent cirrhosis, liver failureand liver cancer.

Given the complex nature of hepasB and the coming of new eecve treat-ments, choosing the right agent can bechallenging. Liaw said the new guidelineswill guide clinicians on how to best usethese drugs to suppress the virus and mini-

mize adverse outcomes.

Downloaditnow!

Over 90 must-have clinical

calculators and scoring tools

for iPhone and iPod Touch

Instant Result Time-efficient Scoring Browse By Category

MIMS Consult

Clinical Calculators At Your Fingertips


43/66


Importance of guidelines

In opening the symposium, panel chair

Professor Jia-Horng Kao, disnguished pro-fessor of medicine at the Naonal Taiwan

University, Taipei, laid out the currentguidelines and reiterated the importance

of evidence-based clinical pracce guide-lines, which are systemacally devel-oped statements to assist praconerand paent decisions about appropriatehealthcare for specic circumstances. Hepointed out that such guidelines serve to

achieve the goal of improving quality of life

and survival of CHB paents through pre-venon of disease progression to cirrhosis,end-stage liver disease, hepatocarcinoma

and death.

In order to prevent disease progression,

said Kao, hepas B virus (HBV) replica-on should be suppressed in a sustainedmanner and one of the ways to do this is

through anviral therapy. However, the

emergence of anviral resistance compro-mises the ecacy of therapy.

Raonale for rst-line anviral

monotherapy

Professor Ji-Dong Jia, hepatologist and

director, Liver Research Centre, BeijingFriendship Hospital, Beijing, China, thendiscussed the raonale for rst-line mono-

therapy recommendaons and reviewedcombinaon therapy data. He said that

the pillars of successful therapy included,

amongst others, potent and durable viralsuppression.

Unfortunately, in using nucleos(t)ide

analogs, drug resistance becomes a majorconcern due to the long-term duraon oftherapy. In general, rst-line therapy shouldbe either entecavir (ETV) or tenofovir (TDF)and second-line therapy should be telbivu-dine (LdT), adefovir (ADV) and lamivudine(LVD). Five-year HBV DNA suppression databy ETV and TDF showed that the numberof paents with extremely low HBV DNA

rises to 94 and 99 percent, respecvely.[Hepatology2010;51:422-30, 62nd AnnualMeeng of the American Associaonfor the Study of Liver Diseases (AASLD);November 4-8, 2011; San Fransisco, US.Poster 1375]

With regard to combinaon therapyinvolving two direct anviral agents, Jia saidthere was no evidence poinng to beer

viral suppression compared with a singleagent. The safety and ecacy of mono-therapy was armed by the Randomized,Observaonal Study of Entecavir to AssessLong-term outcomes Associated withNucleos(t)ide Monotherapy for Paentswith Chronic HBV Infecon (REALM)study. REALM was carried out in China andestablished that ETV monotherapy was

ecacious and safe in a heterogeneousseng. [21st APASL 2011; February 17-20;

Evidence for managing chronic Hep BGuideline recommendaons and supporng data for the long-term management of chronic

hepas B (CHB) were reviewed and discussed by an internaonal panel of experts duringa Bristol-Myers Squibb-sponsored symposium held in conjuncon with the Asian Pacic

Associaon for the Study of the Liver (APASL) conference. Pank Jit Sin reports.


44/66


Bangkok, Thailand. Poster PP05-146]

Evidence from long-term trials and real-

world clinical praccePanel members then presented long-termtrial results and real-world clinical pracceseng supporng data of the use of ETV inCHB paents in Asia and Europe.

Professor Ching-Lung Lai, chair ofMedicine and Hepatology and chief,Division of Gastroenterology and

Hepatology, Department of Medicine,

Hong Kong University, emphasized theimportance of potent viral suppression

and its role in improving long-term paenthealth. On doing so, he revisited the ETV-022/027 studies which had a large num-

ber of Asian parcipants. Paents in thetrials were given either ETV or LVD withthe primary endpoint of seeking histologic

improvements in either arm.

At the end of 48 weeks, 78 percentof paents in the ETV group and 54 per-cent in the LVD group had HBV DNA lev-els


45/66


associated with a lower probability of dis-ease progression, and it was not inuencedby severity of liver disease.

Minimizing the risk of resistance

The last speaker on the panel, Professor

Stephen Locarnini, head of Researchand Molecular Development, VictorianInfecous Diseases Reference Laboratory,Australia, touched on the avoidance ofresistance.

The risk of resistance can be mini-

mized by choosing anvirals that result

in rapid, profound and durable viral sup-pression and have a high genec barrierto resistance, said Locarnini. However, he

noted that none of the traits would work ifpaents do not take their medicine.While current nucleos(t)ide analogs are

generally well-tolerated, he concluded bysaying that doctors should be watchful, asindividual long-term safety proles vary,and that renal monitoring is indicated with

nucleode therapy. [AASLD Pracce guide-lines. Chronic Hepas B: Update 2009;

Accessed February 2012]

Over 90must-have clinical calculators and scoring

tools for iPhone and iPod Touch

Search for MIMS Consult in the App Store now!

Instant Result Time-efficient Scoring Browse By Category

Downloaditnow!

Clinical Calculators

At Your Fingertips

MIMS Consult


46/66


Protease inhibitors improve outlook in Hep C

Rajesh Kumar

Novel direct acng anviral agents(DAAs) currently under developmentpromise to address a huge unmet need in

the treatment of chronic hepas C.Protease inhibitors, the rst generaon

of DAAs, oer much promise to hepa-s C genotype 1 (HCV-1) paents who

respond poorly to the exisng standardof care (SOC) comprising peginterferon/

ribavirin combinaon therapy, accordingto Professor Ed Gane, hepatologist and

deputy director of the New Zealand LiverTransplant Unit in Auckland, New Zealand.

Looking at the impact of HCV genotypeon sustained virologic response (SVR),Gane said peginterferon and ribavirin for

48 weeks has been shown to be associatedwith a SVR rate of 82 percent in paentswith HCV genotypes 2 and 3 comparedwith only 42 percent in those with HCV-1.[Lancet2001;358:958-965].

About 25 protease inhibitors are cur-rently in clinical development, with eight

in phase III. Two such agents, telaprevir

and boceprevir, were approved last year in

Europe and the US for use in combinaonwith the current SOC for the treatment

of chronic HCV-1 in both treatment-naveand experienced paents.

In the Phase III studies of boceprevirand telaprevir, their addion to peginter-feron and ribavirin increased efcacyand shortened the duraon of therapy inpaents with HCV-1.

As a result, the triple therapy is likely tobecome the new SOC, said Gane. However,

it will not be suitable for paents withnon-HCV-1 infecon, or who are intoler-ant of or have contraindicaons to inter-

feron, he said.Over half of the total global burden of

hepas C is in the Asia Pacic region.Although latest data suggests the preva-lence has stabilized and is actually fall-ing, Gane said an ageing cohort and low

rate of eradicaon due to poor treatmentuptake means the proporon of thosewith advanced disease is steadily rising.

The proporon of people who havecirrhosis is esmated to double over the

Protease inhibitors are novel direct actingantiviral agents that may help Hep C genotype 1

patients in particular.


47/66


next 20 years. That will lead to an increasein related complicaons, he said.

The Asia Pacic region has a marked

variaon of HCV genotypes: while HCV-1dominates in north Asia, southern Asiahas genotype 6 and accounts for a third of

all the paents with this genotype whileHCV-3 has become the predominantinfecon in the Indian sub-connent andin Australasia.

Asians with HCV-1, however, respondbeer to the exisng SOC than other

races. The CHARIOT study involving 896paents, including 116 Asians, showeddramac dierence in SVR rates in thetwo races. Treatment-nave Asians withHCV-1 had a beer chance of respondingto the 48-week treatment with a 360 ginducon dose of peginterferon for therst 12 weeks, followed by a standard 180g dose for 36 weeks in combinaon with

ribavirin 1000-1200 g/day, said Gane.Four similar studies have conrmed

beer response among Asians with HCV-1,

apparently due to favorable paent IL28BCC genotype in Asian populaons (70-90percent) compared with Caucasians (30-

40 percent).But paents who failed to adhere to atleast 80 percent of the prescribed therapy,irrespecve of their genotype, had curerates that were 80 to 90 percent lowerthan those who stuck with the regimen.

The biggest issue in treatment of cirrhocpaents, however, is geng them to takethe full dose therapy because their dose

oen needs to be reduced due to seriousside eects, said Gane.

The combinaon of mulple DAAs,which target dierent steps of HCV rep-licaon, should provide interferon-freetreatment regimen. Both ongoing and

planned studies will now determine

which combinaon (protease, nonnucleo-side polymerase, nucleoside polymerase,

NS5A or cyclophyllin B inhibitors) andwhat duraon of therapy will be requiredto opmize care, he added.

Down

load

itnow

!

Clinical Calculators At Your

FingertipsMIMS Consult oers over 90 must-haveclinical calculators and scoring tools foriPhone and iPod Touch.


48/66


Hepatic infusion chemo gains popularity in Asia

Chrisna Lau

Hepac arterial infusion chemotherapy(HAIC) using an implanted port sys-tem has emerged as a treatment oponfor unresectable hepatocellular carcinoma(HCC) in Japan and Korea, with centersreporng good clinical outcomes.

HAIC involves intermient bolus infu-

sion of chemotherapy at an interval of 1to 3 months. The most commonly used

regimens in Japan are low-dose 5-FU pluscisplan, or intra-arterial 5-FU infusioncombined with systemic interferon [IFN]therapy, said Professor Masatoshi Kudo ofthe Kinki University in Osaka, Japan.

According to Kudo, HAIC requires alower drug dose than systemic chemother-

apy, and is associated with less side eects,as well as beer response and survival.The procedure is performed under angio-

graphic guidance and is feasible at outpa-ent clinics. However, it requires experseand great care, and is me consuming.

Although not recommended as a stand-ard of care by the American Associaonfor the Study of Liver Diseases (AASLD)

[Hepatology 2011;53:1020-1022], HAIC iswidely accepted in Japan. The procedure

is recommended by the Japan Society ofHepatology for treatment of mulple (4)tumors or tumors with vascular invasion in

paents with Child-Pugh class A or B dis-ease, and for paents refractory to tran-sarterial chemoembolizaon. [Hepatol Res2010;40:667-685; Dig Dis 2011;29:339-364]

Good results have been reported withHA

medical tribune april 2012 hk

Documents