medical tribune march 2012 hk

www.medicaltribune.com

March 2012

Advancements in the management of anal fistulas

IN PRACTICE

NEWSDaily milk boosts brainpower

CONFERENCEH. pylori eradication altersappetite hormone levels

Turf wars: Resolvinginterdisciplinary conflict incardiovascular imaging

FORUMStudy identifies epilepsy markers in Chinese

HONG KONG FOCUS

Diabetes and its hidden toll

Mayan ruinsAFTER HOURS

2 March 2012

Diabetes and its hidden toll

Rajesh Kumar

Chronic hyperglycemia can damage the heart beyond its effects on the

development of clinical atherosclerotic coronary disease.

This was a key finding of a US study which examined the association between different levels of HbA1c, a marker for diabetes, and cardiac troponin T (cTnT), a blood marker for myocardial injury, in 9,661 patients without clinically evident coronary heart disease or heart failure. [J Am Coll Cardiol 2012;59:484-489]

Using a novel high-sensitivity (hs) cTnT assay, the researchers found that higher baseline values of HbA1c were associated with increasingly higher levels of cTnT

(P<0.001 for the trend). After adjusting for traditional risk factors, patients with HbA1c levels in the ranges of 5.7 to 6.4 percent and ≥6.5 percent were 1.26 (95% CI: 1.01 to 1.56) and 1.97 (95% CI: 1.44 to 2.70) more likely to have elevated cTnT lev-els compared with those with HbA1c levels <5.7 percent, respectively.

Compared with patients with HbA1c 5.7 percent, hs-cTnT values were 25 per-cent higher in persons with HbA1c 5.7 percent to 6.4 percent and 70 percent higher among participants with HbA1c levels ≥6.5 percent. In fully adjusted models, every 1-percentage point higher HbA1c value was associated with a 0.7 ng/L higher value of hs-cTnT (95% CI: 0.5 to 1.0; P<0.001).

A novel high-sensitivity blood marker test has revealed that chronic hyperglycemia may play a role in myocardial injury independent of its effects on the development of atherosclerosis.

3 March 2012

“Our results suggest that chronically elevated glucose levels may contribute to heart damage,” said senior author Dr. Elizabeth Selvin, associate professor in the department of epidemiology at Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, US.

The levels of cTnT detected were about one-tenth of those usually found in patients diagnosed with a heart attack. This sug-gests that hyperglycemia may be related to cardiac damage independent of ath-erosclerosis. The relationship was present at HbA1c levels even below the threshold used to diagnose diabetes.

“Our study hints at other potential pathways by which diabetes and ele-vated glucose are associated with heart

disease,” said Selvin’s colleague Mr. Jonathan Rubin, an internal medicine fellow at the school and the lead study author. “Mainly, glucose might not only be related to increased atherosclerosis, but potentially elevated glucose levels may directly damage cardiac muscle.”

When asked about the findings’ rel-evance for Asian populations, Selvin said there is no reason to believe the relation-ship would be any different in Asians.

“The hs-cTnT test is not yet approved for clinical use, but may be in the future. These data help in our understanding of the clinical implications of this novel hs test for cardiac troponin and suggest that hyperglycemia may contribute directly to myocardial damage,” she said.

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4 March 2012 ForumTurf wars: Resolving interdisciplinary conflict in cardiovascular imaging

Professor Douglas VaughanChair, Department of MedicineFeinberg School of MedicineNorthwestern UniversityChicago, Illinois, US

Battles, discussions and conflicts have existed between departments for dec-

ades over management and development of cardiovascular imaging and institutions.

Unfortunately, departmental organiza-tion into separate “silos” can devastate organizations, killing productivity and push people out the door. It also jeop-ardizes achieving corporate, medicine, and academic goals. Such separation is also not helpful in terms of building a program or serving patients.

There are three main contributors to interdisciplinary conflict related to cardi-ovascular imaging: radiology, cardiology and administration. Radiologists may say things like “it’s my machine” or “I was here first.” Cardiologists may lay claim to patients and the administration of a hos-pital holds the funds. You can see how that conversation doesn’t get very far.

The silo mentality that still exists in many academic institutions and practices is representative of early 20th century organization of labor that really isn’t fit for the way we operate and try to work today in the 21st century.

Many fascinating techniques in imag-ing that are improving the field such as nuclear imaging, computed tomography angiography or cardiovascular magnetic

resonance imaging are often areas around which there is turf conflict because it is unclear who manages the imaging.

Traditionally, most of the imaging field was populated by radiologists. CT and MRI scanning have become highly adopted in the cardiovascular world now, even though radiologists have been using those devices for decades.

These departments can go head-to-head and toe-to-toe to determine who has control over such imaging modali-ties. In the case of the irresistible force versus the immovable object, you can imagine there’s going to be a collision and somebody is going to get hurt.

The reality in 2012 is further compli-cated by the fact that our imaging modal-ities are constantly evolving. In the very near future, the field will be adding new imaging strategies and techniques to our repertoires that allow us to do molecular imaging, to image stem cells and other things we only dreamed of a decade ago.

As we see with tissue echocardiog-raphy, CT and MRI scanning, these are areas where we can do battle or partner and grow these programs.

As a high stakes game, perhaps game theory should be applied to the conversa-tion when we think about how to create interdisciplinary practice with respect to cardiovascular imaging.

Cardiovascular imaging accounts for nearly one-third of all the diagnostic images performed annually in the US. Another third of that one-third are probably

5 March 2012 Foruminappropriate or questionable procedures.

And while the number of imaging pro-cedures continues to grow, revenues for studies continue to fall. If we think people used to battle when there was healthy reimbursement a decade ago, imagine what the battle will be like when reimbursement falls even further.

Technology is complex and evolves rapidly. This is an important determinant in who is involved in performing imaging procedures at any institution. Too often we see individuals interested in gaining control and sacrificing success. However, even with greater numbers of imaging centers that improve access to cardiac CT scans, we cannot be sure this adds to overall patient health.

But there are many stakeholders in the conversation about cardiac imag-ing beyond radiology and cardiology. Hospitals need capital to invest in imag-ing equipment and keep it updated over time. Individual departments are involved, especially in a world where we live in our own financial bubbles without interdisciplinary funds flow or multispe-cialty practice groups.

Faculty are involved as they need to do work that will advance their own careers and practices. Doctors in training need to be proficient in imaging techniques to develop their careers in investigation and clinical practice.

Patients contribute to the conversa-tion. They want safe tests that can give them a prognosis about the state of their health, but they may not know which test is best or provides the most information.

Payers are vitally interested, especially with reduced reimbursements, as they can be gatekeepers of cardiovascular imaging.

So how do we solve the problem? In general, such issues are best dealt with prospectively rather than retrospec-tively. Developing imaging practices and setting guideline benchmark with frank, fair understanding between par-ties ahead of time can save trouble later. Departments should commit to operat-ing on principles rather than politics. It is difficult to put toothpaste back in a tube if there are preexisting arrangements between parties.

For example, during my time at the Vanderbilt integrated cardiovascular institute in Nashville, Tennessee, US, everything lived in that institute — MRI, CT, echocardiology, nuclear and every other kind of imaging. All professional revenues flowed to the institute and people were paid based on activity and their productivity.

The result was less fighting over rev-enues and less fighting over who had to pay for devices. That was a healthy envi-ronment for growing a program, allowing vigorous and robust activity rather than a divisive attitude.

In general, institutions have to grow partnerships between interested parties. It makes a big difference at the end of the day whether all players have healthy, satisfactory relationships with positive partners when dealing with complex issues like cardiovascular imaging.

Integrating clinical and financial goals can work and we’re seeing more of that today than we did a decade ago.

Building walls is not a good strategy for growth and success. Walls divide the haves and have nots. Tearing down walls can make for thriving, robust environ-ment for opportunity and success.

Website: www.ensure.com.hk

7 March 2012 Hong Kong FocusStudy identifies epilepsy markers in ChineseChristina Lau

Variants in a gene encoding a cytoskel-etal protein may increase the risk of

epilepsy in Chinese people by up to 60 percent, according to a joint study by the Chinese University of Hong Kong (CUHK) and the University of Hong Kong (HKU).

Being the first genome-wide associa-tion study on genetic markers for epilepsy, the findings may have important clinical implications for screening patients with brain insults who are at risk of develop-ing epilepsy, and for development of new therapies.

“Brain insults are the major cause of epi-lepsy, accounting for 40 percent of cases. Depending on the severity of insult, 5 to 30 percent of people may develop epi-lepsy afterwards,” said Dr. Patrick Kwan of the Division of Neurology, CUHK. “The fact that the same brain insult leads to epilepsy in some people but not oth-ers suggests that genetic differences may affect susceptibility to the condition.”

The genome-wide association study included 1,087 Chinese epilepsy patients and 3,444 controls. Stage 1 of the study involved genome-wide scanning in 504 patients and 2,947 controls, whereas stage 2 was a replication study in another 583 patients and 497 controls. Patients were recruited from the CUHK Epilepsy Genetics Research Network, a database including 1,800 patients from five Hospital Authority clusters. [Hum Mol Genet 2011, e-pub 9 Dec]

“We found sequence variants in eight genes that differed in frequency between

cases and controls,” reported Professor Pak-Chung Sham of the Department of Psychiatry, HKU.

Among these, the frequency difference for the rs2292096 [G] variant on 1q32.1 in the CAMSAP1L1 gene reached genome-wide statistical significance.

“The CAMSAP1L1 gene encodes a cytoskeletal protein, which may affect neurite growth and hence the risk of epilepsy. The genetic variant we identified is present in 65 percent of Hong Kong Chinese, and increases the risk of epilepsy by approximately 60 percent,” explained Sham.

A potential clinical application could involve genetic screening of patients with brain insults to identify those at high risk of developing epilepsy. “Individuals with these genetic markers may be observed closely and treated promptly if they develop epilepsy. They may also receive interventions to prevent epilepsy after brain insults,” said Kwan. “Our finding also helps scientists better understand how brain insults result in epilepsy, which may lead to new therapies for the condition.”

8 March 2012 Hong Kong FocusThe team is now conducting fur-

ther research on the function of several genes identified in the study, includ-ing CAMSAP1L1 and ERBB4. “We’re studying their normal function, and the effect on cells when more or less of the proteins they encode are expressed,” said Dr. Larry Baum of CUHK’s School of Pharmacy. “We’re also studying the effect of those genetic variants in brain samples.”

Once the functions of proteins encoded

by those genes are known, Baum said it would be possible to design drugs target-ing those proteins or the relevant path-ways. “When the brain doesn’t repair itself correctly after an insult, there may be a ‘short circuit’ of electrical signal causing over-activation,” he told Medical Tribune. “While current epilepsy drugs suppress that short circuit, new drugs could pre-vent the short circuit from forming in the first place by preventing improper repair of the brain insult.”

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9 March 2012 Hong Kong FocusPediatric EEG commonly misused in Hong KongNaomi Rodrig

A local study has found that nearly half of the referrals for standard electroen-

cephalography (EEG) in pediatric practice are inappropriate, prompting the authors to call for more judicious use of the test based on current guidelines. [Hong Kong Med J 2012;18:25-29]

Investigators from the Department of Pediatrics and the Electrodiagnostic Medical Unit at Tuen Mun Hospital evalu-ated the records of 109 children who under-went standard EEG between December 2009 and February 2010.

Overall, 44 percent of the EEG requests were inappropriate with respect to guide-lines, of which 50 percent were for the diag-nosis of ‘funny turns’, 23 percent for febrile convulsions, and 23 percent for monitoring patients with established epilepsy.

According to the guidelines, standard EEG is not recommended in these condi-tions, as it is not helpful or even misleading. Conversely, EEG referrals are appropriate in case of definite or probable epileptic sei-zures and classification of newly diagnosed epilepsy, as well as in cases of encepha-lopathy, neuro-degeneration and organic brain disturbances.

Of the appropriate requests in the study, 89 percent were correctly made to support a diagnosis of epilepsy based on strong clinical suspicion.

Interestingly, both specialists and non-specialists made inappropriate referrals for EEG (45 and 40 percent, respectively). The authors suggest that unrestricted access to standard EEG in Hong Kong

hospitals leads to unjustified requests, in particular from nonspecialists (86 percent of the 109 cases).

“There is considerable potential for unnecessary requests and misinterpreta-tion of the results,” claimed WC Lee et al.

Importantly, the EEG results often do not contribute to clinical management. In the study, EEG results did not affect subsequent management in all inappropriate referrals as well as in 49 percent of appropriate refer-rals. “Overall, the standard EEG contributed to the diagnosis or management in only 28 percent of patients,” they wrote.

These data confirm previous overseas reports that misconceptions about the diagnostic capability of EEG are common, leading to abuses. The authors believe that suboptimal use of the EEG service is typi-cal of most regional hospitals in Hong Kong and the study results can be generalized.

They specifically warn of EEG misuse to exclude epilepsy, which is almost impossi-ble, as the diagnosis of epilepsy is clinical. “Moreover, so-called false-positive EEG findings can be as high as 0.5 percent… This increases the risk of misdiagnosing

10 March 2012 Hong Kong Focusepilepsy and its attendant important con-sequences, including inappropriate drug treatment and the psychological trauma of being’ labeled’ epileptic,” they wrote.

Attributing the pediatric EEG abuse to mis-conceptions regarding its role and limitations,

the investigators suggest that physician edu-cation may help. “Through an educative, non-confrontational approach, and with time to explain guideline recommendations to clinicians, sustainable change in practice could be achieved,” they recommended.

Cough medication abuse linked to muscle damage

Naomi Rodrig

Cough mixture overdose has been asso-ciated with severe folate deficiency, which may cause rhabdomyolysis, as demon-strated in several case reports featured recently in the Hong Kong Medical Journal. [Hong Kong Med J 2012;18:68-69]

According to study authors, from the Department of Psychiatry at Kwai Chung Hospital and the Department of Medicine at Queen Mary Hospital, cough mixture abuse is an emerging problem among young men, and its metabolic consequences have been recognized only recently. These include severe renal damage, metabolic acidosis, and severe folate deficiency that can lead to neurological and hematological effects. However, musculoskeletal side effects have not been recognized as yet.

They reported three cases of young men (age 29-32), who presented with con-fusion, uncoordinated limb movements, rigid limb tone, myalgia and muscle weak-ness. All patients had a history of antipsy-chotic drug abuse and cough medication overdosing (30 cough tablets or >2 bot-tles of cough syrup daily), and were diag-nosed with folate deficiency (125, 63 and 61 µg/mL vs reference level of >164 µg/

mL). An open muscle biopsy in one of the patients showed necrotizing myopa-thy with degenerating fibers and sarco-plasmic vacuolation, while a sural nerve biopsy showed severe axonal degeneration.

Rhabdomyolysis is an uncommon clinical emergency related to illicit drug and alcohol abuse; it may result in renal shutdown, hyper-kalemia, hyperphosphatemia and death.

After excluding the initial differential diagnoses, the authors concluded that folate deficiency was implicated in the mus-cle damage, although myoglobinuria was documented in only two of the patients. Large doses of codeine as well as low folate levels are known to have myopathic effects. “All these are suggestive of a causative effect. Interactions with other components (eg, pseudoephedrine), impurities or addi-tives in the illicit cough mixture might also aggravate the musculoskeletal damage,” they wrote.

They pointed out that cough mixture abuse is often perceived as relatively harmless, but in fact may have damaging metabolic and neuropsychiatric sequela. Therefore, they suggest a high index of sus-picion, so clinicians can initiate early inves-tigation and treatment to minimize any permanent muscle or kidney damage.

11 March 2012 Hong Kong FocusHA to provide interferon for multiple sclerosis patientsChristina Lau

Interferon will be provided to patients with multiple sclerosis (MS) as a Special

Drug under the Hospital Authority’s (HA) expanded Drug Formulary with effect from 1 April. While patient eligibility criteria are yet to be announced, a concern group is urging the HA to adopt internationally rec-ognized criteria so that all patients suitable for the treatment can benefit.

Interferon has been self-financed by MS patients managed in the public sector unless they fulfill the stringent requirements for financial assistance under the Samaritan Fund. Starting next month, the HA will pro-vide interferon treatment to eligible patients at a very low cost. About 90 patients will benefit, according to an HA estimate.

“The HA has yet to announce the cri-teria for patient eligibility. Based on the internationally recognized McDonald Criteria 2010 and the indications for drug use, nearly 170 MS patients in Hong Kong are suitable for interferon treatment,” said Ms. Jintana Sae Sow, Chairperson of the Multiple Sclerosis Concern Group, at a press conference.

She stressed that the HA’s criteria should be consistent with those rec-ognized internationally and take into account the fluctuating course of MS, so that patients in remission can be consid-ered for interferon treatment.

“The criteria should not be more stringent than current requirements of the Samaritan Fund, for which very few MS patients are eligible,” she said. “In addition to the strict

financial assessment, patients are required to pass a test of aided walking of 100 meters. Patients with preserved cognition and upper-arm mobility are excluded.”

In a recent survey conducted by the Concern Group, 42 percent of 82 MS patients said they had to leave their fami-lies and live alone, or give up their jobs or property to apply for Fund assistance.

Among interferon-treated patients, 75 percent said they had to bear full or par-tial cost of the drug; 29 percent said they would not be able to afford the treatment after 3 years.

Furthermore, 33 percent of the patients had reduced interferon use on their own because of financial considera-tions. “This may impair disease control in terms of progression and relapse,” said Dr. Chen-Ya Huang, President of the Hong Kong Brain Foundation, a member of the Concern Group.

For those not treated with interferon, 38 percent indicated that follow-up con-sultations were unnecessary, suggest-ing that some patients might have been lost to follow-up and the number of MS patients is underestimated.

“Interferon has been shown to slow MS progression to disability by about 3 years,” said Professor Vivian Lee of the School of Pharmacy, Chinese University of Hong Kong, a member of the Concern Group. [Mult Scler 2009;15:1286-1294] “The treatment is highly cost-effective. By providing 170 MS patients with interferon therapy, it is estimated the HA could save more than HKD 200 million in 3 years.”

13 March 2012 Hong Kong FocusAF patients on warfarin warned about herbal foodstuffsChristina Lau

Patients with atrial fibrillation (AF) treated with warfarin should watch out

for a number of foods and herbs commonly used in Chinese cooking, as frequent con-sumption of these ingredients is associated with suboptimal anticoagulation control in a recent study.

“Many AF patients know that warfarin interacts with green leafy vegetables and beans, which contain large amounts of vitamin K. But few are aware that foods with herbal ingredients used in Chinese cooking may augment or inhibit its antico-agulation effect,” said Professor Hung-Fat Tse of the Division of Cardiology, University of Hong Kong who led the study.

The study included 250 patients with nonvalvular AF who had been treated with warfarin for at least 6 months. They were asked about consumption of foods with herbal ingredients that may inter-act with warfarin in the past 12 months, using a standardized questionnaire. The researchers then investigated the effect of the concomitant consumption on INR (International Normalized Ratio) control. [J Cardiovasc Pharmacol 2011;58:87-90]

Up to 50 percent of patients reported consumption of foods with herbal ingredi-ents that may interact with warfarin. The most commonly consumed foods were gar-lic (80 percent), ginger (75 percent), papaya (55 percent), green tea (50 percent), ginkgo (40 percent), and Chinese wolfberry (25 per-cent). Herbal drugs such as ginseng (4 per-cent), danshen (1.2 percent) and dong guai

Table. Foods with herbal ingredients that may interact withwarfarin

Increase INR/augment the effect of warfarin:• Chinesewolfberry(杞子)• Danshen(丹參)• Devil’sclaw(南非鈎麻)• Dongquai(當歸)• Fenugreek(葫蘆巴)

• Feverfew(銀菊)• Garlic• Ginger• Ginkgo• Papaya

DecreaseINR/inhibitoryeffectofwarfarin:• Ginseng• Greentea

• StJohn’swort

AdaptedfromJCardiovascPharmacol2011;58:87-90.

(0.8 percent) were uncommonly consumed.“Importantly, frequent users who con-

sumed more than one kind of herb for at least 4 times per week were less likely to stay within the optimal therapeutic INR range of 2-3 than infrequent users who consumed one kind of herb for fewer than 4 times per week,” pointed out Tse. “Frequent users had their INR out of optimal therapeutic range 49 percent of the time, compared with 42 percent of the time for infrequent users.”

“This study highlights the issue of limited knowledge in warfarin-treated AF patients of the potential interaction between herbal substances in foods and warfarin,” he con-tinued. “Although we did not measure the amounts of foods with herbal ingre-dients consumed by the patients, over-consumption of such foods may affect INR control, increasing the risk of stroke or bleeding.”

Tse suggested that warfarin-treated patients should be educated on the foods and ingredients that can potentially affect INR. “Dietary restrictions and regular mon-itoring are important to make sure that INR is maintained within the optimal therapeu-tic range.”

15 March 2012 Hong Kong FocusNew RT system at PWHChristina Lau

A state-of-the-art radiotherapy (RT) system will soon be installed at the

Prince of Wales Hospital (PWH) to improve patient service and enhance medical research and training.

Expected to commence service in 12 months, the TrueBeam RT system enables image guidance, motion management, intensity modulation and stereotatic radi-otherapy at high speed and great preci-sion. The system will facilitate a number of ongoing cancer research projects including stereotatic body RT in medically inoperable

early lung cancer, vertebral metastasis and liver cancer, as well as image-guided RT in prostate cancer using fiducial markers.

“The new system is gaining popularity across the US, Europe and Australasia to tar-get tumors of the lung, liver, pancreas, head and neck, brain, and spine,” said Professor Tai-Fai Fok, Dean of CUHK’s Faculty of Medicine. “Treatment using TrueBeam for challenging cancers such as brain tumors has already started, with thousands of can-cer patients having been treated.”

Acquisition of the system is made pos-sible through a HKD 40 million donation from the Li Ka Shing Foundation.

Removing the root of cancerChristina Lau

Researchers in Hong Kong have devel-oped a novel class of compounds that

can inhibit the growth of cancer stem cells.Cancer stem cells are a small

group of cells in tumors with the ability to proliferate and self- renew, and to differentiate into hetero-geneous cancer cells that constitute the entire tumor mass. Being resistant to con-ventional cancer therapy, they are very difficult to eradicate and are the source of relapse and metastasis.

In a joint study by the Hong Kong Polytechnic University (HKPU), Peking University Shenzhen Graduate School, and Nevada Cancer Institute in Las Vegas, USA, researchers have developed a novel class of compounds that could inhibit the

16 March 2012 Hong Kong Focusgrowth of cancer stem cells. [Cancer Res 2011;71:7238-7249]

The compounds were specific bioac-tive small inhibitors of lysine-specific demethylase 1 (LSD1), a histone dem-ethylase that is highly expressed in many tumors. These LSD1 inhibitors were found to inhibit the proliferation of pluripotent cancer cells, including teratocarcinoma, embryonic carcinoma, and seminoma or embryonic stem cells expressing the stem cell markers Oct4 and Sox2. However, there was little growth-inhibitory effect on non-pluripotent cancer cells or normal somatic cells.

“The potential clinical applications of LSD1 inhibitors include treatment of malig-nant germ cell tumors, such as teratomas or teratocarcinomas, embryonic carcinomas, seminomas, choriocarcinomas, and tumors of yolk sac, which often become resistant to initial platinum treatment,” said Dr. Tao Ye of HKPU’s Department of Applied Biology and Chemical Technology who led the study. “The compounds can also be used to remove teratomas or embryonic car-cinomas during stem cell-based therapy, and to inhibit organ-specific cancers with stem cell-like cells, such as breast and ovarian cancers.”

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17 March 2012 Hong Kong FocusFurther curbs on obstetric services for non-localsNaomi Rodrig

Against growing public discontent denouncing the increasing number of

mainland Chinese women giving birth in Hong Kong, the Hospital Authority (HA) has recently reviewed and revised its regulations on obstetric service provision in 2013.

“A review of the 2012 delivery bookings by the HA’s Taskforce on Obstetric Services for Non-eligible Persons (NEP) showed that there is a higher demand from local expect-ant mothers than the original forecast,” the HA spokesperson said.“As a result, Princess Margaret Hospital has ceased to accept bookings from non-local mothers for the rest of 2012, while Queen Mary Hospital will also adjust and reduce the obstetric quota for non-locals in coming months.”

Last year, about 41,000 mainland NEP gave birth in Hong Kong hospitals, account-ing for nearly half of the total births in the city. Given the burden on the obstetric and neonatal units with the surge in non-local expectant mothers using public hospital ser-vices, the government has limited the num-ber of non-local births in the city in 2012 to 34,000. While described as ‘a step in the right direction’, it does not address the plight of local pregnant women who often are una-ble to reserve hospital beds for delivery because of the influx of non-locals.

Having considered the service capacities and priorities for local expectant mothers in 2013 and the consequent demand for neonatal services, the Taskforce reiter-ated the priority for local pregnant women in booking of obstetric services, and pro-posed a preliminary plan on quotas for

non-locals in 2013.“The prime responsibility of our hospitals

is to ensure adequate and up-to-standard services for local mothers as well as the newborns. We will closely monitor the ser-vice booking situation and adjust the ser-vice quota to ensure local demand is always met,” said Dr. Wai-Lun Cheung, HA Director (Cluster Services) who chaired the meeting.

The Taskforce recommended that four public hospitals (Kwong Wah, Princess Margaret, Prince of Wales and Tuen Mun) will not accept any bookings of non-local mothers next year, while the quota of the remaining four hospitals (Pamela Youde Nethersole Eastern, Queen Elizabeth, Queen Mary and United Christian) will be further reduced to below 3,000 in total.

The proposed plan will be submitted to the Food and Health Bureau for considera-tion against the supply and demand situa-tion of obstetric services in both the public and private sectors.

As complementary measures, the govern-ment is tightening up the borders and crack-ing down on so-called birth agents shuttling mainland women into the city to give birth. In mid-February, a mainlander who brought pregnant women into Hong Kong was sen-tenced to 10 months in prison.

18 March 2012 Hong Kong FocusSurvey reveals unmet needs in schizophrenia managementChristina Lau

Schizophrenia patients are more willing to be treated with long-acting inject-

able atypical antipsychotics but are fre-quently turned down by their physicians when requests for such medications were made, according to a local survey.

The Hong Kong Familylink Mental Health Advocacy Association interviewed 270 schizophrenia patients and their family members in 2011 to investigate patients’ medication use, knowledge of available medications and their healthcare needs. The mean age of the patients and caregiv-ers was 42 and 51, respectively.

More than 90 percent of patients in the survey were on oral antipsychotics. However, 48 percent had discontinued oral medications on their own.

While 33.9 percent of patients or fam-ily members had asked doctors for new-generation oral antipsychotics, such requests were turned down 26.4 percent of the time.

“Nearly half of the respondents believed that new long-acting injec-tions are as effective as and more con-venient than oral antipsychotics. For these reasons, they indicated a higher willingness to be treated,” reported Dr. Marcus Chiu of the Department of Social Work, Hong Kong Baptist University, at a press conference.

Although 64.7 percent of the respond-ents had asked doctors for long-acting injections, such requests were turned down 66.7 percent of the time.

“Schizophrenia patients often discon-tinue oral medications because of forget-fulness, side effects, and misperceptions that their condition has improved. While atypical oral antipsychotics are associ-ated with fewer side effects, compliance remains a problem as long-term treat-ment is required,” said Dr. Sik-Chuen Ting, Specialist in Psychiatry. “Long-acting injectable atypical antipsychotics can improve compliance and therefore reduce the risk of recurrence, as the injections are administered by healthcare profes-sionals every 2 or 4 weeks.”

However, these injections are not com-monly used in clinical practice because of cost constraints. Furthermore, previous research indicates that healthcare pro-fessionals often believe injections would cause pain, and that patients would be reluctant to change treatment. Patients’ compliance with oral antipsychotics has also been overestimated. [J Clin Psychiatry 2004;65:120-131]

“Use of long-acting injectable atypi-cal antipsychotics is associated with a healthcare cost saving of HKD 50 mil-lion per year compared with oral medi-cations,” said Chiu, who was referring to a retrospective study conducted by the Chinese University of Hong Kong’s School of Pharmacy in 2003–2007.

The researchers thus suggested that the Hospital Authority should provide atypical antipsychotics such as long-acting injections for schizophrenia patients, to reduce additional costs associated with managing relapses.

20 March 2012 Hong Kong FocusHong Kong Events

16th Annual Scientific Meeting

Hong Kong Society for Infectious

Diseases

10/3

Info: UBM Medica Pacific Limited

Tel: (852) 2155 8557 / 3153 4374

Fax: (852) 2559 6910

E-mail: [email protected]

www.hksid.org

5th Annual Therapist Symposium –

Management of Rheumatoid Arthritis

Hong Kong Society for Hand Therapy

16/3

Info: Ms. Chloe Lam

Tel: (852) 2468 5232

Fax: (852) 2468 5234


www.hksht.org

25th HKSSH Annual Congress

Hong Kong Society for Surgery of the

Hand

17/3-18/3

Info: Dr. HK Wong

Tel: (852) 2990 3406

Fax: (852) 2990 3477


www.hkssh.org

27th AADO-OLC-SABL Comprehensive

Bioskill Course on Fracture Fixation

Orthopedic Learning Center,

Department of Orthopedics and

Traumatology, CUHK

24/3-25/3

Info: Ms. Charis Lau

Tel: (852) 2632 1654


www.olc-cuhk.org

Annual Scientific Meeting 2012

Hong Kong Thoracic Society and

American College of Chest Physicians

25/3


Tel: (852) 2155 8557 / 2116 4348

Fax: (852) 2559 6910


www.hkresp.com


International Symposium on Spine

and Paravertebral Sonography for

Anesthesia and Pain Medicine 2012

Department of Anesthesia and

Intensive Care, CUHK

29/3

Info: Ms. Ruby Ng

Tel: (852) 2632 2735

Fax: (852) 2637 8010


www.usgraweb.hk/issps2012

OLC- SABL Spine Workshop

Orthopedic Learning Center,

Department of Orthopedics and

Traumatology, CUHK

31/3-1/4

Info: Ms. Mandy Tse

Tel: (852) 2632 1653


www.olc-cuhk.org

Left Atrial Appendage Closure

Workshop Hong Kong 2012

Division of Cardiology and Institute of

Vascular Medicine, CUHK

27/4-28/4

Tel: (852) 2647 6639

Fax: (852) 2144 5343


www.icc-hongkong.com/laa/

20th Annual Scientific Congress

Hong Kong College of Cardiology

4/5-6/5

Info: Ms. Lynn Lam / Ms. Queenie Wong

Tel: (852) 2911 7902 / 2911 7923

Fax: (852) 2893 0804 / 2838 7114

E-mail: [email protected] /

[email protected]

www.hkcchk.com

Hospital Authority Convention 2012

7/5-8/5

Info: Ms. Cynthia Kong

Tel: (852) 2300 6557

Fax: (852) 2890 7726


www.ha.org.hk/haconvention/hac2012


9th Hong Kong International

Orthopedic Forum – Orthopedics and

Pain

26/5-27/5

Department of Orthopedics &

Traumatology, HKU

Info: Ms. Chang

Tel: (852) 2255 4257


Hong Kong Society of Dermatology and

Venereology

10/6


Tel: (852) 2155 8557 / 2116 4348

Fax: (852) 2559 6910


2nd IDKD Intensive Course in Hong

Kong – Diseases of the Abdomen and

Pelvis

16/6-19/6

Info: Swire Travel Limited

Tel: 852 (0) 315 188 19

Fax: 852 (0) 315 463 24


www.idkd.org

12th Asian Conference on Clinical

Pharmacy

Department of Pharmacy, CUHK

7/7-9/7


Tel: (852) 2155 8557 / 3153 4374

Fax: (852) 2559 6910


www.accp2012.org

2012 Conference of Asia Oceania

Research Organization on Genital

Infection and Neoplasia (AOGIN 2012)

Department of Obstetrics and

Gynecology, HKU

13/7-15/7

Info: PC Tour and Travel

Tel: (852) 2734 3315

Fax: (852) 2367 3375


www.ogshk.org/2011/AOGIN_2012.pdf


Annual Scientific Meeting

Hong Kong Institute of Musculoskeletal

Medicine

21/07-22/07


Tel: (852) 2155 8557 / 3153 4374

Fax: (852) 2559 6910


www.hkimm.hk

5th International Infection Control

Conference

Hong Kong Infection Control Nurses’

Association; HKU; Hong Kong College of

Radiologists

24/8-26/8

Info: MV Destination Management Ltd.

Tel: (852) 2735 8118

Fax: (852) 2735 8282


www.mvdmc.com/hkicna/index.html

2012 FDI Annual World Dental

Congress

FDI World Dental Federation

29/8-1/9

Tel: (852) 2528 5327

Fax: (852) 2529 0755


www.fdiworldental.org

14th Hong Kong Diabetes and

Cardiovascular Risk Factors East Meets

West Symposium

1/10-2/10


Tel: (852) 2155 8557 / 2116 4348

Fax: (852) 2559 6910


www.eastmeetswest.org.hk


Hong Kong Society of Pediatric

Respirology

8/10


Tel: (852) 2155 8557 / 2116 4348

Fax: (852) 2559 6910


www.hkspr.org


7th International Huaxia Congress of

Endocrinology

Hong Kong Society of Endocrinology,

Metabolism and Reproduction

30/11-2/12

Info: Ms. Veronica Cheng

Tel: (852) 2734 3312

Fax: (852) 2367 3375


http://www.endocrine-hk.org/

huaxia2012poster.jpg

17th Congress of the APSR Hong Kong

2012

Hong Kong Thoracic Society

14/12-16/12


Tel: (852) 2155 8557 / 2116 4348

Fax: (852) 2559 6910


www.apsr2012.org/

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b Efficacy of this alternative regimen has been demonstrated for infections caused by S. pneumoniae (excluding MDRSP), Haemophilus influenzae, Haemophilus parainfluenzae, Mycoplasma pneumoniae and Chlamydia pneumoniae.c Where Pseudomonas aeruginosa is a documented or presumptive pathogen, combination therapy with an antipseudomonal β-lactam is recommended.

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26 March 2012 NewsMortality predictors not ready for clinical useRadha Chitale

Despite the existence of a variety of prognostic indices to determine the

risk of death among older adults, research-ers who reviewed them cited insufficient evidence for use of these tools in wide-spread clinical practice.

“By our measures, no study was com-pletely free from potential sources of bias… even if [data] quality barriers are overcome, important limitations remain,” they said.

The survey included 16 validated indi-ces that predicted the absolute risk of all-cause mortality in patients whose average age was 60 or older. The clinical settings included hospitals, nursing homes and com-munities but excluded indices estimated from cohorts in intensive care units, those that were disease specific and those that were in-hospital. [JAMA 2012;307:182-192]

The greatest challenge for such indices, the researchers noted, was the inability to account for all factors that can affect survival. Key factors such as comorbid conditions, genetics and social supports are omitted.

Less common comorbid conditions, such as Parkinson’s disease or dementia, tended not to be included in the indices.

The indices did not account for genetics in life span and did not include relevant infor-mation on parent or sibling ages of death.

Conversely, protective factors such as social supports and community involve-ment were also not considered.

The researchers said the purpose of prognostic indices is to allow clinicians to shift to more sophisticated clinical decision making when treating older adults rather

than falling to arbitrary age-based cutoffs. However, only very high or very low mortal-ity risk is likely to influence clinical decisions.

“There may be a limited role for the high-est-quality indices in the right settings,” the researchers said. “If patient character-istics align closely with those of the devel-opment or validation cohorts, clinicians may find prognostic information useful to help inform, though not replace, their clini-cal judgment. Prediction rules have been shown to outperform clinicians in terms of prognostication, whereas human predic-tion on its own is fraught with bias.”

However, only three indices predicted greater than an 80 percent risk of mortal-ity in the highest risk group.

In an accompanying editorial, Dr. Thomas Gill, of the Yale School of Medicine, New Haven, Connecticut, US, was not opti-mistic about the potential for mortality-based indices, because of the burden of meticulous data collection in order to achieve an accurate assessment. [JAMA 2012;307:199-200]

“Given the central role of prognosis in clinical decision making, waiting for the ideal index to be developed, validated, and rigor-ously tested would not be prudent,” he said.

The best predictors of mortality in older people are comorbidities and func-tional status.

Instead of mortality, Gill suggested focus-ing on predicting life expectancy.

“A preferred alternative is a single [devel-oped and validated] prognostic index (or perhaps a small number of indices) based on estimated life expectancy, a metric that is familiar to both physicians and patients.”

27 March 2012 NewsOverweight, obese at higher risk ofdisc degenerationRajesh Kumar

Overweight or obese adults are signifi-cantly more likely to have disc degen-

eration than those with a normal body mass index (BMI), a large Chinese study has found.

Previous research has linked higher BMI to low back pain. Researchers led by Drs. Dino Samartzis and Kenneth Cheung at the University of Hong Kong went a step further by investigating the association between elevated BMI and presence, extent, and severity of lumbar spine disc degenera-tion in adults. [Arthritis Rheum 2012; DOI: 10.1002/art.33462]

A total of 2,599 adults (1,040 men and 1,559 women, mean age 42 years) were recruited from Southern China between 2001 and 2009 and their radiographic and clinical assessments and spinal MRIs were taken. The subjects were from diverse social and economic backgrounds and were recruited regardless of whether they had lower back pain or not.

Mean BMI was significantly higher in sub-jects with disc degeneration (mean=23.3 kg/m2) compared to those without (mean=21.7 kg/m2) [P<0.001]. A significant increase in the number of degenerated levels (P<0.001), global severity of disc degenera-tion (P<0.001), and end-stage disc degen-eration with disc space narrowing (P<0.001) was noted with elevated BMI and was more pronounced in obese individuals.

“Our research confirms that with ele-vated BMI there is a significant increase in the extent and global severity of disc

degeneration. In fact, end-stage disc degen-eration with narrowing of the disc space was more pronounced in obese individu-als,” said Dr. Samartzis.

Practice implications Physicians should become more familiar with various risk factors associated with disc changes, and screening and follow-up of the spine in obese individuals can help prevent future back-related problems, he added.

The findings should also motivate over-weight or obese patients even further to have a more active lifestyle, eat healthier, and lose weight, said Samartzis.

When asked about the poor affordability and accessibility of MRI, Cheung said the modality is a very useful tool to diagnose the cause of back pain if the patient is in pain.

“If the patient is not in pain, then screen-ing and identifying early disc degeneration does not add value to the overall manage-ment. Of foremost importance is a healthy life-style with regular exercise, careful weight control and avoid smoking,” he said.

The authors also noted that disc degen-eration is a complex process involving struc-tural and chemical changes of the disc. They recommended that future studies that investigate risk factors for disc degeneration should take into account the impact of over-weight and obesity on the disease.

“Deeper understanding of how elevated BMI contributes to disc degeneration and low back pain could aid in the development of novel interventions that can improve quality of life for those with these disabling conditions,” said Cheung.

REGISTRATION:Title: ❏Professor ❏Dr. ❏Mr. ❏Ms.

Name: Job Title:

Department: Organization:

Address:

Tel: Fax: E-mail:

Meeting Registration:❏ HKD 150 per person for members of organizing bodies, supporting organizations, and full-time staff working in

department of medicine of the New Territories East Cluster. Please specify your organization/hospital .❏ HKD 300 per person for non-members.

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Payment:Cheque payable to UBM Medica Events (Hong Kong) Ltd – EMW and mail to 27/F., OTB Building, 160 Gloucester Road, Wanchai, Hong Kong.

Enquiry:Ms. Chloe Wong, UBM Medica Pacific Limited (T: +852 2155 8557 or 3153 4374; E: [email protected])

MEET THE EXPERTS

HONG KONG DIABETES AND CARDIOVASCULAR RISK FACTORS FORUM –

www.eastmeetswest.org.hk

* Light lunch will be provided.* Accredited for CME, CNE, CDE and CPD points.

14 April 2012 (Sat) * 12:30 – 17:00InterContinental Grand Stanford Hotel, Tsim Sha Tsui East

Case Discussion on Diabetes & Hypertension presented by endocrinologists & family physicians• Interactive forum to enhance collaboration between

family physicians & specialists to optimize treatment of diabetes and hypertension

• Management of these common conditions with reference to the “Hong Kong Primary Care Reference Framework for Diabetes Care and Hypertension”

• Latest update on the pharmacological treatment of diabetes

Organizers:

Hong Kong Institute of Diabetes and ObesityThe Chinese University of Hong Kong

Hong Kong Foundation for Research and Development in Diabetes

Hong Kong Association for the Study of Obesity

Hong Kong Atherosclerosis Society UBM Medica Pacific Limited

✂

29 March 2012 NewsCoffee may reduce fibrosis risk in patients with NASHElvira Manzano

Increased intake of coffee may hold the key to decreasing the risk of advanced

fibrosis – scarring – in people with fatty liver disease, research suggests.

In a study of 306 patients with nonal-coholic steatohepatitis (NASH), high con-sumption of coffee significantly decreased the formation of excess fibrous connec-tive tissue in their liver. [Hepatology 2012; 55(2):429-36. doi: 10.1002/hep.24731]

“Our study is the first to demonstrate a histopathologic correlation between fatty liver disease and estimated coffee intake,” said study author Dr. Stephen Harrison, lieutenant colonel in the US Army based at Brooke Army Medical Center in Fort Sam Houston, Texas, US. “Moderate coffee con-sumption may be a benign adjunct to the comprehensive management of patients with NASH.”

Harrison and his team studied the cof-fee consumption of participants from a previous non-alcoholic fatty liver disease (NAFLD) study and NASH patients treated at the center’s clinic and categorized them into four groups – patients with no sign of fibrosis (controls), steatosis, NASH stage 0-1, and NASH stage 2-4.

There was a significant difference in the caffeine consumption of patients with stea-tosis compared to patients with NASH stage 0-1 (P=0.005). Additionally, coffee consump-tion was significantly greater in patients with NASH stage 0-1 than with NASH stage 2-4 (58 percent versus 36 percent of caf-feine intake from regular coffee, P=0.016).

“There was a stepwise decrease in cof-fee consumption as fibrosis increase,” Harrison explained. “This would suggest that other properties of coffee beyond caffeine may affect disease progression in NASH patients.”

Caffeine intake has long been associated with a reduced risk of hepatocellular car-cinoma, and reduced fibrosis and cirrhosis in patients with chronic liver diseases such as hepatitis C. [Hepatology 2009;50:1360; Hepatology 2010;51:201]

It has also recently been suggested that coffee may protect against diabetes and endometrial cancer.

“Knowing the beneficial effects of coffee intake on liver diseases, future prospec-tive research should examine the amount of coffee intake on clinical outcomes,” Harrison concluded.

Commenting on the study, Dr. Vincent Wong, professor, department of medicine and therapeutics director, Center for Liver Health, The Chinese University of Hong Kong said the current paper “adds to the existing literature showing that the same phenom-enon is observed in NAFLD patients.

“The study has a relatively large sample size. The existing literature is rather con-sistent on the association between coffee intake and liver injury. However, limited by the nature of observational studies, causal relationship is difficult to estab-lish,” he said. “For example, instead of direct causal effect, coffee intake may be associated with less liver fibrosis through differences in smoking, alcohol use and physical activity.”

29 February 2012

31 March 2012 NewsTai chi improves balance, reduces falls in Parkinson’sRadha Chitale

Tai chi exercises proved better at improv-ing balance and reducing the risk of

falls among adults with Parkinson’s disease compared with strength training or simple stretching, according to a study.

“Physical activity has been shown to retard the deterioration of motor functions and to prolong functional independence,” the study authors said.

Patients with the neurodegenerative disease are left with impaired balance, less stability, gait dysfunction, poorer quality of life due to reduced functional abilities and an increased risk of falls.

These symptoms are largely unaffected by drug therapy and exercise is recom-mended. However, the researchers note that resistance training, which has been shown to address balance and strength def-icits, requires monitoring and equipment.

“We hypothesized that tai chi would be more effective in improving postural stabil-ity in limits-of-stability tasks than a resist-ance-based exercise regime or low impact stretching,” they said.

A group of 195 patients with mild-to-moderate Parkinson’s disease were ran-domly assigned to receive twice-weekly 60-minute sessions of tai chi, resistance training or stretching (control) for 24 weeks. [N Engl J Med 2012;366:511-9]

The tai chi protocol was designed to tax balance and gait by focusing on symmetric and diagonal movement, weight shifting, controlled center of gravity displacement, ankle sways, and anterior-posterior and

lateral stepping. Resistance training focused on the mus-

cles important for posture, balance and gait, including squats, lunges and heel and toe raises, using weighted vests and ankle weights.

Seated and standing stretches for the upper body and legs provided a low inten-sity control group.

Tai chi patients performed better than the resistance and stretching groups in the primary outcome measures testing the limits-of-stability, which assesses how far patients can lean in a number of directions without falling, and at directional control, which measures movement accuracy.

There were 381 falls in 76 patients overall but the incidence rate was 67 per-cent lower for the tai chi group compared with the stretching group (0.22 vs 0.33, P=0.005). Tai chi patients experienced marginally fewer falls than the resistance training group, whose incidence rate was 0.47, but this was not significant (P=0.05).

Tai chi patients performed better in all secondary outcome measures compared with the stretching group, including gait, knee movement, functional reach, and time to stand from sitting. They performed better than the resistance group at stride length and functional reach.

The effects were maintained 3 months after completing intervention.

The trial did not measure the net gain of tai chi exercise but only as compared to low intensity, low impact stretching regimes.

“Clinically, these changes indi-cate increased potential for effectively

32 March 2012 Newsperforming daily life functions, such as reaching forward to take objects from a cabinet, transitioning from a seated to a

standing position (and from standing to seated), and walking, while reducing the probability of falls,” the researchers said.

Daily milk boosts brain powerElvira Manzano

Frequent intake of dairy food – an important step to building strong bones and prevent-

ing osteoporosis – also enhances cognitive functioning, recent research has shown.

A cross-sectional meta-analysis of the dietary habits and mental functioning of 972 adults in the US has found that indi-viduals who consumed dairy products once a day had significantly higher scores in memory and other cognitive tests com-pared with those who never or rarely con-sumed dairy food. Individuals with high milk consumption were also five times less likely to fail the tests compared with non-milk drinkers. [International Dairy Journal 2011.DOI:10.1016/j.idairyj.2011.08.001]

While little is known about the under-lying mechanisms of dairy’s benefits on cognitive functioning, the authors said its unique nutrient content might play a role.

“Dairy foods contain a number of important nutrients such as calcium, whey protein, vitamin D, magnesium and phos-phorus,” said lead researcher Ms Georgina Crichton, from the Nutritional Physiology Research Centre, University of South Australia, Adelaide, Australia.

Adult subjects aged 23 to 98 who were included in a community-based study of cardiovascular disease (CVD) risk factors and cognitive functioning were put through a series of brain and cognitive challenges to assess their visual-spatial, verbal and

working memory, scanning tracking and executive function. Those who scored the highest across all tests consumed the most milk and dairy products, the study found.

Cognitive performance scores increased linearly across increasing categorical levels of dairy food intake for 7 out of 8 outcome meas-ures. Milk drinkers also maintained healthier diets overall compared to non-drinkers.

“Frequent dairy food intake was associ-ated with better cognitive performance across a range of cognitive domains in this dementia-free, community dwelling popu-lation,” the authors said. The association between greater dairy food intake and better cognitive performance remained significant even after adjusting for several cardiovas-cular risk factors such as CVD prevalence, hypertension and wait circumference.

While the authors said the study has a num-ber of strengths, including large community sample, longitudinal studies are still needed to improve understanding of the association between dairy intake and cognitive function.

“As brain disorders are most likely to impact upon more than a single cognitive ability or behavior, cognitive function needs to be assessed with a thorough neuro-psychological test measuring a range of cognitive abilities.”

Frequent intake of dairy products such as milk, cheese and yoghurt has also been shown to help reduce weight and con-trol blood pressure and diabetes, all of which are risk factors for CVD that increase the likelihood of cognitive dysfunction.

34 March 2012 NewsPhysical activity lowers CV risk, better in moderation? Elvira Manzano

Mild-to-moderate levels of exercise may be more beneficial than strenu-

ous exercise when it comes to preventing heart attack in the long term, according to a recent study.

Researchers analyzed data from INTERHEART – a long-running case-control study on heart attacks involving 24,000 patients from 52 countries in Asia, Europe, the Middle East, Africa, Australia and North and South America – and found that only mild-to-moderate physical activity at work was protective against MI. [Eur Heart J 2012; DOI:10.1093/eurheartj/ehr432]

However, all levels of intensity of exer-cise during leisure time reduced the risk of heart attack. The odds of acute MI were lower with mild exercise (OR 0.87) and moderate to strenuous exercise (OR 0.76). The risk was even lower in patients who exercised 30 minutes or less a week. Surprisingly, no further risk reduction was seen in patients who exercised more than 60 minutes a week.

“Given previous reports indicating a dose-response protective effect of exercise duration, this result was somewhat unex-pected,” said lead author Dr. Claes Held from Uppsala Clinical Research Center, in Uppsala, Sweden.

For occupational activity, both light and moderate activities were associated with decreased odds of acute MI compared with being sedentary (ORs 0.78 and 0.89, respectively). However, heavy physical labor (OR 1.02) did not lower the risk of

heart attack. Held and colleagues included in the

study 10,043 individuals who had an MI and 14,217 controls. Compared to controls, individuals who had an acute MI were more likely to be sedentary during leisure time and at work (P<0.001 for both). Sedentary lifestyle was associated with greater risk of MI after adjusting for age, sex, country level income, smoking, alcohol, education, hypertension, diabetes and other factors.

Interestingly, people who owned a car and a television were at greater risk of MI than those who had none of these machines (P=0.054). While Held acknowl-edged that a TV and a car increase physi-cal inactivity, he said a prospective trial is needed to validate their study.

The authors said their findings highlight the protective effect of physical activity across all country income levels in addition to the known benefits of modifying tradi-tional risk factors.

“It’s an interesting finding that goes with the theme… Daily moderate physi-cal activity should be encouraged for both men and women of all ages as a protec-tive act against cardiovascular disease,” the authors said. “Walking and bicycling is recommended as a method to promote physical activity.”

They attributed the increase in seden-tary lifestyle to increasing urbanization, mechanization at work, motorized trans-portation, easy access to activity-limiting devices (cars, escalators, elevators) and appliances (TV, computers), which all pro-mote sedentary behavior.

Before Before

Case 1 Case 2

ACharity Program

byThe Center for Dr. Wu's Bunion Surgery

Dr. Daniel Wu is pleased to announce that his “syndesmosis procedure” for bunion correction will soon surpass the 1,000-consecutive-procedure milestone in 2012. To celebrate this special occasion, the Center would like to make its unique surgery available to twelve charity case patients free of charge.

The terms and conditions for this charity program are posted on our website www.bunioncenter.com. We welcome referral of possible candidates for a complimentary consultation and x-ray evaluation.

Dr. Daniel Wu would like to sincerely thank his anesthesiologists (Dr. C.K. Chan and his associates) for kindly waiving their charges also.

There will be informal discussions of the “Reasons and Results” of the syndesmosis procedure at our center. Please call 2525-5035 for more information.

The Center for Dr. Wu’s Bunion Surgery

The syndesmosis procedure uses a unique non-bone-breaking technique that has enjoyed some of its great satisfactions from the most demanding cases.

36 March 2012 Conference Coverage53rd Annual Meeting of the American Society of Hematology, 10-13 December 2011,San Diego, California, US

Optimizing treatment for H. pylori infectionsLeonard Yap

Selecting better antibiotic therapy strat-egies for Helicobacter pylori infections

and educating patients about compliance with their medications is the best way to avoid antibiotic resistance, says an expert.

Using a combination of antibiotics with the right duration of therapy, in addi-tion to improving patient compliance to these medications, will prevent H. pylori resistance to antibiotics, said Dr. Francis Megraud, professor of bacteriology, University Victor Segalen Bordeaux 2 and head of the National Reference Center for Helicobacters, France. Currently, clarithromycin is a commonly used anti-biotic for H. pylori infections, but “the burden of clarithromycin resistance is steadily increasing.”

Resistance of H. pylori to metronidazole and clarithromycin has been reported, with metronidazole resistance being very com-mon. This has an important clinical impact on dual antibiotic therapies and standard triple therapies, which include the use of a

proton pump inhibitor (PPI) and two anti-biotics. When PPI-based triple therapies with amoxicillin or clarithromycin and met-ronidazole are used, the resistance could be overcome in up to 75 percent of cases. [Gut 1998;43 (suppl 1):S61-5]

“Several factors influence eradication failure. Obviously, if you don’t take the drug, [there is] lack of compliance [result-ing in a decrease in the eradication rate], and, if you have [high] gastric acidity, especially if you are an extensive metabo-lizer of PPI, you decrease your eradication rate. It has also been shown that when you have a high bacterial load you are less likely to eliminate the bacteria – pos-sibly, the presence of intracellular bacte-ria or the impact of altered immunity [can decrease the eradication rate of H pylori],” Megraud said.

The Second Asia-Pacific Consensus Conference was convened to review cur-rent information on H. pylori management and a set of updated consensus state-ments was issued. (Box 1) [J Gastroenterol Hepatol 2009;24:1587-600].

• In Asia, the currently recommended first-line therapy for H. pylori infection is PPI, amoxi-cillin and clarithromycin for 7 days.

• There is an increasing rate of resistance to clarithromycin and metronidazole in parts of Asia. This has led to reduced efficacy of PPI-based triple therapy.

• Fourteen-day triple therapy confers limited advantage over 7-day triple therapy in H. pylori eradication rates.

Box 1: Consensus statements on H. pylori management.


• Bismuth-based quadruple therapy is an effective alternative to first-line therapy for H. pylori eradication.

• There are currently insufficient data to recommend sequential therapy as an alternative first-line for H. pylori therapy in Asia.

• Salvage therapy for H. pylori eradication includes: (i) a standard triple therapy that has not been previously used; (ii) bismuth-based quadruple therapy; (iii) levofloxacin-based triple therapy; and (iv) rifabutin-based triple therapy.

• CYP2C19 polymorphisms may affect H. pylori eradication rates in PPI-based triple ther-apy. Choice of PPI or increasing the dose is a more practical approach than CYP2C19 genotyping in the clinical setting to overcome CYP2C19 polymorphisms in the context of salvage therapy.

• Smoking adversely affects the outcome of H. pylori eradication therapy.


Liver enzyme polymorphisms may affect drug responseLeonard Yap

Cytochrome P450 2C19 (CYP2C19) poly-morphisms may play a significant role

in the success or failure of treatments for Helicobacter pylori, say a panel of experts.

CYP2C19 polymorphisms have been known to affect the metabolism of certain types of pharmaceuticals, said Associate Professor Varocha Mahachai, Division of Gastroenterology, Chulalongkorn University, Bangkok, Thailand.

This is particularly true of proton pump inhibitors (PPI), which are commonly used to control gastric acidity in H. pylori infec-

tions. Patients who have the ‘extensive metabolizer’ polymorphism tend to have poor control of gastric acid as they metabo-lize the drug too quickly before the PPI can do its job, she said. [Aliment Pharmacol Ther 1999;13 Suppl 3:27-36]

Professor Fock Kwong-Ming, of the Faculty of Medicine, National University of Singapore and senior consultant gas-troenterologist at Changi General Hospital said, “CYP2C19 polymorphisms may affect H. pylori eradication with standard triple therapy. The way to overcome this effect is to increase the dose of the PPI or change to a PPI that is less affected by CYP2C19.

“Three studies, one from Japan, one from Taiwan and one from Korea, show that the CYP2C19 [polymorphisms] were a factor [in H. pylori eradication].”

PPIs such as omeprazole and lansopra-zole are mainly metabolized by CYP2C19 in the liver. There are three types of CYP2C19 polymorphisms: extensive, intermediate and poor metabolizer. Extensive metabo-lizers are typically less responsive as they metabolize PPIs much faster than the inter-mediate and poor metabolizer. Therefore, eradication rates for H. pylori are typically lower for extensive metabolizers. [Clin Pharmacol Ther 2001;69(3):158-68]

The Second Asia-Pacific Consensus Guidelines for H. pylori infection includes this statement: “CYP2C19 polymorphisms may affect H. pylori eradication rates in PPI-based triple therapy. Choice of PPI or increasing the dose is a more practi-cal approach than CYP2C19 genotyping in the clinical setting to overcome CYP2C19 polymorphisms in the context of sal-vage therapy*.” [J Gastroenterol Hepatol 2009;24:1587-600]

*Salvage therapy: therapy after multiple (at least two) treatment failures with different regimens.

CYP2C19 polymorphisms may affect H. pylori eradication with standard triple therapy. The way to overcome this effect is to increase the

dose of the PPI or change to a PPI that is less affected by CYP2C19‘‘

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H. pylori eradication alters appetite hormone levels

Malvinderjit Kaur Dhillon

A change in Helicobacter pylori coloni-zation status can potentially induce

changes in ghrelin and leptin levels, thus influencing metabolic status and body weight, says an expert.

Dr. Fritz Francois, a gastroenterolo-gist at the New York University Langone Medical Centre, New York, US, said, “Our group began to look at the functional ele-ments of the gut as they relate to satiety hormones, and we focused on two in par-ticular: leptin (an anorectic peptide which signals you when you have had enough to eat and, in fact, has a very strong anorec-tic effect) and ghrelin, perhaps one of the only known orexigenic peptides, one that stimulates appetite.”

“We are looking at the issue not only from the perspective of what is going on in H. pylori positive and negative [subjects], but also the impact of eradication on a meal. Ultimately, what you really want to know is the change – when you give some-body a meal, when somebody eats, what happens to these particular hormones before and after?” he added.

The study by Fritz and his team involved a group that were primarily male and in their 60s. Blood was drawn at baseline and the subjects were fed a standardized meal. Blood was drawn an hour later and under-went eradication of H. pylori. The proce-dure was repeated after 6 weeks.

“There is a drop in ghrelin levels

post-meal, which is exactly what you would expect. After the eradication treatment, ghrelin levels are higher pre-meal com-pared to the pre-eradication group. Compared to the post-meal levels, there isn’t a drop that you would expect. As for leptin, we found an increase in leptin levels in both instances,” he said.

Fritz and his group also looked at body mass index (BMI) changes of these patients over a span of 18 months and found a positive co-relation between fasting ghre-lin and change in BMI. As ghrelin levels increased with eradication, BMI levels also increased. [BMC Gastro 2011;11:37]

Varying studies demonstrated different effectsof H. pylori eradication on preprandial andpostprandial ghrelin and leptin levels.

42 March 2012 PainDistraction and placebo potent pain-relieversElvira Manzano

Combining distraction techniques with a placebo cream was more effective

at reducing thermal pain than distraction methods alone, a study has found.

“The reductions were additive, sug-gesting that the executive demands of the working memory task did not interfere with placebo analgesia,” said the researchers, from Columbia University, New York, US.

Taken together, these data suggest that placebo does not depend on active redi-rection of attention and that expectancy and distraction can be combined to maxi-mize pain relief.

“The most important finding for clini-cians is that distraction and placebo can be combined with no loss of efficacy,” said Mr. Jason Buhle, who was conducting the research as part of his doctoral disserta-tion at Columbia University, New York, US. “Distraction and placebo don’t interfere with each other.”

On a larger perspective, it implies that there are multiple routes to pain modula-tion which can be engaged without the use of drugs.

In the study, 33 individuals attached to a heating device on their forearms reported less pain when they performed a difficult mental test as pain was being delivered. Pain was further reduced when they were given the distracting test and a placebo cream at the same time. [Psychol Sci 2012 Jan 18; Epub ahead of print]

In the distraction test, participants were given a series of letters and were asked to recall if each letter mentioned had been

listed earlier. In another experiment, they were asked to apply cream on their skin and told it was pain reliever. Another group applied the same cream but was told it was a regular cream.

Buhle said one benefit of using both pla-cebo and distraction is that the combina-tion is more powerful than either alone. Although their study did not directly address other possible benefits, since the two techniques appear to rely on different mechanisms, he said it is likely that they will show different efficacy under differ-ent contexts. “For example, placebo may be more useful in longer lasting pain situ-ations, like chronic pain. Distraction may be more useful when pain is brief, such as during wound care.”

Placebos reduce pain by inducing a psy-chological response or an expectation of relief on the part of the recipient. Its use however has been controversial as patients are somewhat deceived into taking a “med-ication” that has no proven therapeutic effect. Critics say such a deceit can under-mine the essential trust between patients and physicians. Once patients learn they are taking placebos, the perceived ben-efits also tend to dissipate. Studies have also shown that placebo interventions have no important clinical effects in gen-eral, but could influence patient-reported outcomes, particularly in pain.

Meanwhile, distraction techniques such as storytelling, reading, playing games and blowing are particularly useful at allevi-ating pain in children. While the present study did not compare the efficacy of dif-ferent distraction techniques, the literature

43 March 2012 Painsuggests there might be significant differ-ences among them.

Buhle said the most effective distrac-tion seems to occur when executive atten-tion and working memory resources are maximally absorbed in an unrelated task. “Something active, like a video game, would generally work better than some-thing passive, like a movie.”

He explained that the task should be difficult enough to be challenging, but not so difficult that the patient gives up. Motivation also comes into play. “We motivated participants by the promise of

bonus money for good performance, but making the task fun (like a video game) would likely work better in a clinical con-text. Distraction must also be constant,”

Buhle said even a very difficult task won’t work if frequent lulls occur during which only minimum processing is needed. “It only takes a moment to process pain, and pain might grab one’s attention in these lulls, reducing the efficacy of the distrac-tion task.”

While confident with their results, he said his team is currently doing a follow-up study.

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44 March 2012 PainWalking canes reduce knee pain Radha Chitale

Walking canes helped reduce pain and improved function in adults with

knee osteoarthritis, according to a study that researchers said was the first to exam-ine the benefits of this common gait-assis-tance device.

Average pain scores between patients who used a cane every day and patients who used no gait-assistance devices after 2 months was 3.84 and 5.95, respectively, on a 10-point visual analog scale (P<0.001). [Ann Rheum Dis 2012;71:172–179]

Pain among cane users fell compared to baseline (average score 5.63). Pain scores remained consistent for those who did not use canes.

“Patients with knee osteoarthritis gener-ally shift their weight nearly completely to the medial compartment during gait,” said researchers from Universidade Federal de Sao Paulo in Brazil. “Therefore, decreas-ing the load on the medial compartment should be one of the treatment objectives for such patients.”

Sixty-four patients with knee osteoar-thritis were randomized to use a meas-ured-to-fit wooden T-handled cane every day or no walking device for 60 days.

Patients maintained usual treatment for knee osteoarthritis and were evaluated at baseline, 30 days and 60 days for pain, function, general health, energy expendi-ture, cane use and pain medication use.

The treatment group was also given a 5-minute tutorial by a physiotherapist on optimal cane use. They were instructed to hold the cane contralateral to the

most affected knee, what angle to hold the leg and arm and positioning the cane while standing.

Previous studies have shown that con-tralateral cane use reduces the load and force on the knee and lets the knee and cane arm move together for a normal gait pattern.

A 6-minute walking test showed that cane users increased the distance they walked from 396 meters at baseline to 404 meters after 2 months (P<0.001).

The control group improved from 396 meters at baseline to 406 meters after 2 months (P=0.96).

The researchers did not find significant differences between functional improve-ment with cane use, though cane users tended towards functional improvement.

Cane users experienced more energy expenditure at baseline but this decreased over time. Cane users also took fewer pain medications after 2 months compared to the control group (P<0.001) and reported decreased pain following the walking test after 30 and 60 days.

“This probably demonstrates adaptation to cane use, by reducing the weight load on the affected joint during gait, thereby reducing pain…,” the researchers said.

The results are limited by the short follow up time, particularly given that patients use canes for the rest of their lives, and by not being widely extrapo-lated to other populations of patients with knee problems or those with different degrees of osteoarthritic severity, though the researchers said a cane could benefit them too.

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46 March 2012 PainNon-drug approaches help alleviate cancer pain Elvira Manzano

Non-pharmacological, psychosocial interventions are a valid and effective

option for the treatment of pain in patients with cancer, according to a recently pub-lished meta-analysis.

“Pain is one of the most common, bur-densome and feared symptoms experi-enced by patients with cancer,” said Dr. Paul B. Jacobsen, lead study author and associate director for Moffit’s Division of Population Science, Tampa, Florida, US. “The positive findings from this meta-anal-ysis considerably advance support for the importance of psychosocial interventions in reducing pain in cancer patients.”

Jacobsen and colleagues analyzed 37 randomized controlled studies of psy-chosocial interventions involving a total of 4,199 adult patients with cancer. The studies were published between 1966 and 2010. [J Clin Oncol 2012. Jan 23. Epub ahead of print]

Across the studies, psychosocial interven-tions were found to provide weighted aver-aged effect sizes of 0.34 (95% CI 0.23-0.46; P<0.001) for pain severity and 0.40 (95% CI 0.21-0.60; P<0.001) for pain interference.

In interpreting their results, the authors concluded that such interventions pro-vided medium-sized effects in statistical terms, in terms of reducing pain severity and the degree to which pain related to cancer and its treatment interfered with patients’ lives.

They also revealed that skill-based approaches, for example relaxation and hypnosis, tended to be more effective

at reducing pain severity compared with educational approaches, such as teaching patients how to use their medications.

“Psychosocial interventions on the whole do work,” said Professor Cynthia Goh, senior consultant, department of pal-liative medicine, National Cancer Center Singapore. “The findings are relevant because the article looks at how good the evidence is for psychosocial interventions to alleviate cancer pain,” she said. “It is very important for patients to understand their pain and learn how to control it with the help of their doctors and therapists.”

Sometimes, a simple explanation repeated as necessary is enough to help a patient learn how to take their medicines for pain and for treatment of side effects, or how to avoid certain situations which

Relaxation and hypnosis reduce pain incancer patients.

47 March 2012 Painmake the pain worse so they can feel they are in control, Goh explained. “But in some chronic pain situations, patients need more than explanations given at a medi-cal consultation. Sometimes, they need to go through certain kinds of training to help them think about their pain in a different way, or change their behavior which makes the pain worse.”

She said these kinds of training may be done in a group, or individually. “I have seen patients who have undergone cognitive behavior therapy and benefited from it.”

Other interventions include more con-tact with a nurse or a therapist for follow-up and education about their pain.

Goh said the study has been carefully

done and the information it provides is val-uable and adds to existing knowledge. “I think it is important that any interventions be properly evaluated through randomized controlled trials, and meta-analyses of such trials. But it is particularly important when it comes to psychosocial interventions, as there is less standardization of such inter-ventions, and many medical doctors, who are more used to prescribing drugs or doing operative procedures, are less con-vinced of their efficacy.”

Up to one-third of cancer patients suf-fer from moderate to severe pain which interferes with sleep, daily life activi-ties, enjoyment of life, work ability andsocial interactions.

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49 March 2012 In Pract iceAdvancements in the management ofanal fistulasAnal fistula is usually the result of a chronic infection in select individuals who happen to have intra-sphincteric or extrasphincteric glands. In this article, Drs. Koh Poh Koon, Fran-cis Seow-Choen, Lim Jit Fong and Ho Kok Sun, colorectal surgeons at the Novena Colorec-tal Centre in Singapore, elucidate on the cause of this painful condition and review latest advancements in its clinical management.

IntroductionMost cases of anal fistula are a result of a chronic infection of an anal crypt gland or so called cryptoglandular infection.1-3 These infections can only occur in people with intra-sphincteric or extrasphincteric anal glands and therefore not everyone can develop anal fistula as most people only have anal glands in the intramucosal plane.4 The worldwide incidence of anal fistula is estimated to be about 9 cases per 100,000 people.5

The condition usually starts as an infec-tion or abscess at the anal region, char-acterized by a redness and swelling with throbbing pain and sometimes fever.4 When the pus drains externally, a small channel between the anal canal and the skin near the anus is formed. The exter-nal end of a fistula then appears as a hole on the skin from which pus, blood or stool may discharge.

Repeated unsuccessful attempts by the body to heal may lead to a hard nodule at the external opening that occasionally

closes up, causing debris entering the internal opening to be trapped in the tract and setting up recurrent episodes of peri-anal sepsis.5

Anal fistulae are classified as simple or complex, or according to their anat-omy— inter-sphincteric, trans-sphincteric, supra-sphincteric or extra-sphincteric. Trans-sphincteric and ‘high’ fistulas are more likely to occur in females, and in patients with pre-vious perianal sepsis or surgery for fistula. External openings close to the posterior mid-line almost always underlie simple fistulas, whereas postero-lateral external openings are predictive of complex fistulas.1

Cryptoglandular anal fistula are not associated with infection by extraordinary organisms.6 Nearly twice as common in men than in women, an anal fistula can also be caused by inflammatory bowel disease such as Crohn’s disease or specific infec-tion, for example in tuberculous fistula. People with HIV are also at increased risk of developing the condition. Other spe-cific causes include birth related injuries

Dr. Koh Dr. Seow-Choen Dr. Lim Dr. Ho

50 March 2012 In Pract icewith ano-vaginal fistula and prostatic and urethral injuries leading to ano-urethral and ano-prostatic fistulas. These fistulas are normally not considered together with cryptoglandular anal fistula.

DiagnosisFor effective treatment of a cryptoglandu-lar anal fistula, the following information must be ascertained:

1. The presence of a specific cause for the fistula

2. The location of the internal opening and its relation to the dentate line

3. The morphology of the tract and the amount of anal sphincter muscles involved

4. The presence of any other secondary tracts

Treatment of specific fistulasThe exclusion of a specific cause for the anal fistula like tuberculosis is important as the specific treatment of these causa-tive factors will cure the fistula without need for surgery. Similarly ano-vaginal or ano-urethral fistula should be treated spe-cifically if healing is to ensue.

While the external opening of the chan-nel is clearly visible, finding the internal opening can be more challenging. The anatomy of a simple tract is usually easily defined by an examination under anesthe-sia and using the following instruments:

• Fistula probe — An instrument spe-cially designed to be inserted through a fistula. The most efficacious and commonly used around the world is the Lockhart-Mummery fistula probe.

State-of-the-art clinic equipped with the latest technologies for the management of patients with anal fistulas.

51 March 2012 In Pract iceThis is a series of about four probes with various angles of the probe head enabling the surgeon to probe tracts of varying complexities.

• Anoscope — To view the anal canal.• Surgeon’s digit — Many doctors for-

get that one of the best methods to determine the anatomy of any anal fistula is the well trained index finger of the surgeon. Bi-digital palpation with the thumb outside and the index inside the anus is important for accu-rate understanding of the patho-anat-omy of the fistula. The relationship of the fistula to the sphincters and the direction and presence of any second-ary tracts can be assessed as well with the well trained finger.7

For more complicated fistulae, visualiza-tion of the tract morphology can be com-plemented by the use of:

• Diluted methylene blue dye — Dye is injected into the fistula in an operat-ing room. Whilst methylene blue may be used by some surgeons, we do not normally recommend it as it some-times stains normal tissues making identification of tracts from normal tissues even more difficult.1

• Fistulography — Injection of a contrast solution into a fistula followed by an X-ray of the affected area. This sort of radiological examination is favored by some surgeons but we have not found it useful as the tracts seen on radio-graphs are not easily translated into the anatomy seen during surgery.

• Magnetic resonance imaging (MRI) — This examination is often reserved for the most complex fistulae and expert radiological interpretation can often give a good idea of the complexity of

tracts that are present. However the problem again is similar to that of translating those radiological inter-pretations into useable information at surgery.

• Endoanal ultrasound – A useful tool for surgeons who need a simple and inex-pensive method of confirming what his skilled fingers are already telling him regarding the anatomy of the complex fistulas.7 Endoanal ultrasound is also good for assessment of anal sphincter function before surgery both to deter-mine anal function adequacy and for medico-legal protection.

Treatment optionsCryptoglandular fistulas are treated surgi-cally. Specific fistulas may require specified treatment, for example tuberculous fistula or Crohn’s fistula. Simple fistulas may be treated by fistulotomy or simple lay open, but complex or high fistulas that may implicate a significant amount of sphinc-ter muscles require careful evaluation and more complex surgical procedures. In all instances, the objective should be to eradi-cate the fistula without compromising fecal continence. Important considerations include the complexity of the fistula and the strength of the anal sphincter muscle. Acute perianal abscesses should be laid open as soon as practicable and if a fistula is present this should be laid open if the internal opening is easily found.8-11

Fistulotomy is a common surgical proce-dure in which the surgeon cuts open the whole length of the fistula, from the inter-nal opening to the external opening and drains out all the contents. Curettage of all granulation tissue is important to allow the wound to heal. This then heals into a

52 March 2012 In Pract iceflat scar. Fistulotomy essentially opens a “tube” into a “ravine” which then fills up in time to heal. For simple low-lying fistu-lae, this is often all that is sufficient. Long tracts heal faster when the wound edges are marsupialized.12

For more complex fistulae or fistulae with a very high internal opening, the fol-lowing options may be employed:

A fistuloscope for video-assisted anal fistula treatment (VAAFT)

Cutting/Loose Seton Techniques: In the loose seton technique, the surgeon uses a surgical suture called a seton to help drain the fistula and further establish the tract. This seton can be left in situ as long as drain-age is good and the patient is happy with-out acute flare-ups or abscess recurrence. Cutting or tight setons are setons that are tightened around the anal muscles and inserted into fistula tracts in an attempt to force the seton to cheesewire out and result in a high tract moving progressively lower with each tightening. Setons can be difficult to manage and both tight setons and ayurvedic medicated setons can be very painful.13-16

Fibrin glue: This is a less invasive surgical option where the surgeon uses fibrin glue, made of plasma protein, to plug the cav-ity and seal the fistula. The fibrin plug then

promotes ingrowth of tissue to obliterate the tract. Whilst initial results were promis-ing, this technique has fallen out of general favor due to a very high recurrence rate.

Anal fistula plug: As the name suggests, the technique uses a collagen tissue to plug the fistula and acts as a scaffold to promote healing. Initial reports of 80 per-cent success rates have not been repeated by other investigators and this technique might be useful only in simple tracts with-out side tracts or secondary extensions.

Advancement Flap Procedure: The inter-nal opening of the tract is excised and a flap of the rectal mucosa or better still mucosa plus rectal muscle wall is elevated and used to close the internal opening. The external tract is curetted and allowed to drain through the external opening. This method is used frequently for high tracts as it results in better results than using either anal fistula plug or fibrin glue. Flaps may be advanced outwards or inwards but length should not exceed width by more than twice the distance. However failure is not infrequent and may result in a bigger defect than was present originally.

LIFT Procedure: Ligation of Inter-Sphincteric Fistula Tract (LIFT) involves the careful delineation of the anatomy of the fistula tract using injections and probes and the isolation of the tract as it traverses within the inter-sphincteric space. The por-tion of the tract within the intersphincteric space is then ligated and excised, discon-necting the tract from the internal opening. The internal opening is ligated closed and therefore does not allow further ingress of faecal matter therefore allowing healing to progress. This leaves behind the exter-nal opening to drain and gradually heal over time. However there is a significant

53 March 2012 In Pract icewound in the inter-sphincteric space that sometimes causes problems with healing although most cases heal well.

VAAFT: A new technique, video-assisted anal fistula treatment (VAAFT) is a mini-mally invasive and sphincter-saving tech-nique for treating complex fistulas. The main feature of this technique is the ability to view the fistula from the inside of the tract so that it can be eradicated under direct vision using a fistuloscope.

The procedure allows for accurate iden-tification of the internal opening and the secondary tracts or abscess cavities with formal closure of the internal opening. It obviates the need for blind probing of the tract and minimizes the risk of iatrogenic creation of false tracts. Because it affords direct visualization of the tract anatomy, there is no longer any need for expensive imaging using MRI. This technique com-prises diagnostic and operative phases and is performed as a day surgery under regional or general anaesthesia.

ConclusionAbscess management is fairly straightfor-ward with incision and drainage being the hallmark of therapy. But the management of fistula itself is much more complicated. It requires striking a balance between rates of healing and potential alteration of fecal continence. Up to 20 percent of patients may develop some level of incontinence after fistula surgery using the traditional techniques. This can potentially be vastly reduced with the use of novel VAAFT tech-nique which does not sacrifice sphincter muscle integrity.

Although no single technique is appropriate for all patients and all fistula types, appropriate selection

of patients and choice of repair tech-nique should yield higher success rates with lower associated morbidity.

References

1. Br J Surg 1992;79:197-205

2. Br J Surg 1993;80:1627

3. Sem Colon Rectal Surg 1999;9:157

4. Dis Colon Rectum 1994;37:1215-8

5. Chapter In: Anal Fistula. Chapman and Hall. 1996

6. Br J Surg 1992;79:27-8

7. Br J Surg 1991;78:445-7

8. Aust NZ J Surg 1993;63:485-9

9. Dis Colon Rectum 1996;39:1415-7

10. Dis Colon Rectum 1997;40:1130-31

11. Dis Colon Rectum 1997;40:1435-1438

12. Br J Surg 1997:105–107

13. Br J Surg 1994;81:1214

14. Br J Surg 1995;82:426

15. Tech Coloproctol 2001;5:137-141

16. Colorectal Disease 2003;5:373

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55 March 2012 CalendarMarch68th Annual Meeting of the American Academy of Allergy, Asthma and Immunology 2/3/2012 to 6/3/2012Location: Orlando, Florida, US Info: American Academy of Allergy, Asthma and Immunology Tel: (1) 414-272-6071Email: [email protected] Website: www.aaaai.org

2012 Highlights of ASH® in Asia3/3/2012 to 4/3/2012Location: Singapore Info: ASH Customer Relations DepartmentTel: (1) 202-776-0544Email: [email protected] Website: www.hematology.org/Meetings/Highlights/6836.aspx

20th Annual Meeting of the Asian So-ciety for Cardiothoracic Surgery 8/3/2012 to 11/3/2012Location: Bali, Indonesia Info: Asian Society for Cardiothoracic Surgery Tel: (1) 62-21-566-5993 Email: [email protected] Website: www.ascvtsbali2012.org

61st American College of Cardiology Annual Scientific Session 24/3/2012 to 27/3/2012Location: Chicago, Illinois, US Info: American College of Cardiology Tel: (1) 202 375-6000

Email: [email protected] Website: www.acc.org

15th World Congress of Anesthesiologists 25/3/2012 to 30/3/2012Location: Buenos Aires, Argentina Info: WF SA World Congress of Anesthesiologists Email: [email protected] Website: www.wca2012.com

9th European Congress on Menopause 28/3/2012 to 31/3/2012Location: Athens, Greece Info: European Menopause and Andro-pause Society Email: [email protected] Website: www2.kenes.com/emas/pages/default.aspx

AprilWorld Congress of Cardiology Scien-tific Sessions18/4/2012 to 21/4/2012Location: Dubai, UAEInfo: World Congress of Cardiology Email: [email protected] Website: www.world-heart-federation.org

24th European Congress ofUltrasound in Medicine and Biology22/4/2012 to 24/4/2012Location: Madrid, Spain Tel: (34) 913 61 2600

56 March 2012 CalendarFax: (34) 913 55 9208Email: [email protected] Website: www.euroson2012.com

III NWAC World Anesthesia Convention (NWAC 2012)24/4/2012 to 28/4/2012Location: Istanbul, TurkeyTel: (41) 22 908 0488Fax: (41) 22 906 9140Email: [email protected] Website: www.nwac.org

May

American Thoracic Society International Conference 2012 (ATS 2012)18/5/2012 to 23/5/2012Location: San Francisco, California, US Tel: (1) 212 315 8652Email: [email protected] Website: www.thoracic.org/go/interna-tional-conference

19th WONCA Asia Pacific Regional Conference24/5/2012 to 27/5/2012Location: Jeju, Korea Tel: (82) 2 566 6031Email: [email protected]: www.woncaap2012.org

Upcoming

2012 American Society of ClinicalOncology Annual Meeting01/6/2012 to 05/6/2012Location: Chicago, Illinois, US Tel: (571) 483 1300Email: [email protected] Website: chicago2012.asco.org

10th Royal College of Obstetricians and Gynecologists International Scientific Congress05/6/2012 to 08/6/2012Location: Kuching, Malaysia Tel: (603) 6201 1858Email: [email protected] Website: www.rcog2012.com

15th Biennial Meeting of the European Society for Immunodeficiencies (ESID 2012)03/10/2012 to 06/10/2012Location: Florence, ItalyTel: (41) 22 908 0488Fax: (41) 22 906 9150Email: [email protected]: www.kenes.com/esid

42nd Annual Meeting of the International Continence Society15/10/2012 to 19/10/2012Location: Beijing, ChinaTel: (41) 22 908 0488Fax: (41) 22 906 9140Email: [email protected]: www.kenes.com/ics

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58 March 2012 After Hours

Yen Yen Yip recounts walking among ancient Mayan monuments, lasting reminders of one of the world’s greatest lost civilizations.

The Mayans introduced chocolate, corn and squash to the world. They

also developed the mathematical con-cept of zero and were experts in astron-omy without the aid of telescopes. Their civilization, established around 1800 BC, influenced life in present day Mexico, Honduras, Guatemala and Northern El Salvador, but started to decline during 8th and 9th centuries.

The monuments of the ancient Mayans remain today as testaments to their advanced state of develop-ment. In the Mexican states of Yucatan and Quintana Roo, three archeological sites provide fascinating insights into the Mayan way of life thousands of years ago.

Chichen ItzaChichen Itza, a UNESCO World Heritage site, is often the focal point of Mayan lore, and with good rea-son. Its structures served a varied range of purposes that illustrate the complexities of ancient Mayan

Mayan ruins – remnants of a lost civilization

culture, rituals and practices. At the height of its prominence from AD 900 to 1050, Chichen Itza was the centre of economic, religious and cultural activi-ties – a regional capital for north and central Yucatan.

The crown of the monuments in Chichen Itza is El Castillo (The Castle) – an imposing, square-based pyramid that showcases Mayan knowledge of math-ematics, astronomy and architecture. About 30m high, it was built integrating



elements of the Mayan calendar: each stairway had 91 steps, which when mul-tiplied by four sides, plus the top plat-form, gave 365 (the number of days in the solar year). Each side of the pyramid had 18 terraces flanking the stairways (18 being the number of months in a Mayan religious calendar), which fea-tured a total of 52 panels (52 being the number of years it takes to converge the religious and solar calendars). Every year during the spring and fall equinox, the rays of a setting sun align the shad-ows on the northern stairway to form a gleaming diamond-backed rattlesnake slithering down the pyramid.

El Castillo was designed with acoustic effects as well: by clapping at the base of the pyramid, sound waves rebound along the steps of the pyramid in a chirp-ing echo – imitating the call of the Quetzl bird sacred to Mayans.

The peak of the pyramid provides a bird’s eye view of other buildings of Chichen Itza – the ball court, where the ancient Mesoamerican ball game was played and the captain of the winning team would have been decapitated

in an honor sacrifice; the Temple of the Warriors, where hundreds of square and round columns were built to distin-guish the achievements of generals and warriors; and the Wall of Skulls, where it was believed that the heads of sacrifi-cial victims were placed.

TulumNestled on 12-meter-high cliffs, the coastal ruins of Tulum are impassive and enduring against the glittering azure Caribbean waves. Iguanas stretch out on its ancient sun-baked craggy stone blocks,



their beady lizard eyes peering out of leathered brown faces. Palm fronds sway to winds blowing in from the seas while the camera lenses of countless tourists click away in an excited rhythm.

Tulum was first mentioned in 1518, when a contingent of Spanish con-quistadors following the coast of the Yucatan peninsula spotted the city and compared its grandeur to that of Seville in Spain. It is believed that the Spanish also introduced Old World diseases that eventually wiped out the city; the site was abandoned by the end of the 16th century.

Modern day archeological investiga-tions determined that Tulum flourished between the 13th and 15th centuries. Artifacts that were excavated suggested that the city served as an important confluence point for land and maritime trade routes, where merchants bought and sold flint and ceramics, copper rat-tles and rings, and obsidian – prod-ucts that originated from a range of cities from Central Mexico to Central America.

Religion was an impor-tant facet of Mayan life. Among the

various deities, the Descending God was a figure distinct to Tulum. Worshipped for his association to the setting sun and the planet Venus, the Descending God is always depicted upside down above the doorways of Tulum structures. His feet and legs, spread open in a U shape, point upwards, and his hands are clasped together with his head div-ing downwards. At Tulum, the Temple of the Descending God is another tes-tament to Mayan expertise in architec-ture and astronomy. During the winter and summer solstices, a porthole in the



oceanfront wall of the temple allows the dawn light to shine through and hit the corners of other structures close by in a starburst effect.

CobaAbout 45 km from Tulum lies another Mayan site – Coba. Its highlight is the temple pyramid of Nohoch Mul. At 42 meters tall, Nohoch Mul rears up like an island above the green canopy of the encroaching jungle. Tourists clamber to the peak of the pyramid on all fours like insects, stabilizing their bodies with their hands grasping for handholds as their feet balance on the lower steps. 120 steep steps later, a look down from the top delivers an alarming jolt of vertigo: the ground looks so far away. A verdant expanse stretches out into the horizon – there are no other tall buildings in sight – and what were tall trees at ground level now look like bushy green twigs. This could easily have been the view commanded by Mayan high priests performing rituals at the top of Nohoch Mul.

A significantly larger site than Tulum, Coba e n c o m p a s s e s

an area of 80 km2. It had trade relations with the coastal city, though its size sug-gests that Coba likely rivaled Chichen Itza in social and political status. Coba is esti-mated to have held about 50,000 inhab-itants at its height. Despite its present day remoteness in an area overgrown with jungle, Coba must once have been a prosperous trade center that maintained contact with other Mayan cities through road works called sacbe. Some of these ancient highways reached the Caribbean coast, and the longest traveled 100 km to the precincts of another city, Yaxuna.

62 March 2012 Humor

“Excessive consumption of seafood like lobster, for example, can increase bad cholesterol levels

or something much, much more serious!”

“I know your condition is very serious, but think of all the other serious conditions you don’t have!”

“Don’t worry about the hallucinations you’ve been having lately, it’s only your imagination!”

“I’m the Doctor here, so I will decide if you’re sick or not!”

“He’s going to live, but he still thinks you should remarry!” “There you are. Been waiting long?”

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