medical magazine august 2013

8/20/2019 Medical MAGAZINE August 2013

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August 2013

www.medicaltribune.com

EULAR updates RA

recommendaons

Heavy burden of viral

hepas in the Asia

Pacifc region

FORUM

Diagnosing and managing

hip impingement

IN PRACTICE

CONFERENCE

AFTER HOURS

Rome – The Eternal City

WHO launches worldwide hepatitis

network


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2 August 2013

WHO launches worldwide hepatitis

network

Elvira Manzano

Anew global movement against hepa-titis which aims to bring about inter-national collaboration and stem the

spread of this viral infection worldwide, waslaunched at the recent Asian Pacic Associa-tion for the Study of the Liver (APASL) con-gress held in Singapore.

The network, a collaboration of the WorldHealth Organization (WHO), the WorldHepatitis Alliance and the Coalition for theEradication of Viral Hepatitis in Asia Pacic(CEVHAP), aims to build global initiativesand strengthen capacities to raise awareness,promote partnerships, mobilize resources,and provide screening, care and treatment for500 million people worldwide aicted with

hepatitis.“Every day, clinicians witness the signi-

cant challenges that national health servicesface in combating viral hepatitis,” said Pro-fessor Lim Seng Gee, APASL 2013 chair anda CEVHAP founding member. “We hope theGlobal Hepatitis Network will inject newvigor into the global and regional response.A systematic and coordinated response across

Asia Pacic is essential to combat these dis-eases.”According to the latest Global Burden of

Disease Study, 1.4 million people die from vi-ral hepatitis each year, similar to deaths fromHIV/AIDS and higher than from tuberculosisand malaria. However, until recently hepatitishas not been geing the same level of aen-tion and resources as tuberculosis and ma-laria.

“The major global health funds still excludehepatitis and despite signicant advance-

ments in treatment, the funding situation hasled to an era of neglect and spiral in deaths,”said Mr. Charles Gore, president of the WorldHepatitis Alliance, at the network launch.

The Asia Pacic bears the brunt of the bur-

den, with 74 percent of the total hepatitis Bpopulation living in the region.

In Singapore, 160,000 people or 2.7 per centof the population has hepatitis B or C. Whilethe country has had great success with child-hood immunization of hepatitis B, Singapore“cannot rest on its laurels,” said SingaporeHealth Minister Gan Kim Yong.

“We need to continue to innovate and ndnew ways to address our healthcare challeng-es. We need to continually invest in researchto help us beer understand the diseases anddevelop improved, more cost-eective diag-noses and treatments.”

Professor Stephen Locarnini, CEVHAP joint secretary and director of the WHO Re-gional Reference Laboratory for Hepatitis Bat the Victorian Infectious Diseases ReferenceLaboratory (VIDRL), said the real challenge

is to make medicines accessible and aord-able to all. “My lab is commied to devel-

Seventy-four percent of the world’s hepatitis B and C population residein the Asia Pacic.


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3 August 2013

New drug corrects abnormal sleep cycles

due to blindness

Laura Dobberstein

T

asimelteon, a novel circadian regula-tor with selective agonist activity formelatonin receptors, has been shown

to improve the synchronization of circadianrhythms in completely blind patients withnon-24 hour sleep-wake disorder.

“Tasimelteon addresses the root cause ofthis disorder by reseing the circadian clockin the brain,” explained the study’s lead au-thor, Dr. Steven W. Lockley, neuroscientist atBrigham and Women’s Hospital and associateprofessor at Harvard Medical School in Bos-

ton, Massachuses, US. “The medication isable to replace the time cue usually provided

by light and synchronize the circadian clockin totally blind people.”

In the multicenter study, 84 patients whoexhibited abnormal sleep cycles due to blind-ness were randomized to double-blind treat-ment with either tasimelteon 20 mg or place-

bo daily, given 1 hour prior to a xed chosen

bedtime for 6 months. The researchers collect-ed urine samples starting 2 weeks aer treat-ment began. Melatonin and cortisol levels in

oping cheaper diagnostic tests and quanti-tative assays to accurately diagnose chronichepatitis and monitor treatment response. Ifwe can only treat patients eectively, we can

reduce liver cancer by 50 percent, and that isthe most important take-home message.”Aer the ocial launch, the network will

invite as members WHO collaborating cen-ters and relevant UN agencies, research in-

stitutions, professional organizations suchas APASL, patient groups, laboratories andother developmental agencies that fund inter-national health initiatives.

“WHO will use its unique convening roleto unite a large group of people interested indoing viral hepatitis prevention and controlactivities,” said WHO Professor Hande Har-manci.

the urine were measured to determine thecircadian period. Study participants reportednight-time sleep, day-time naps and overallfeelings of well-being.

“None of the traditional medications usedto treat sleep disorders or sleepiness have thisability and therefore tasimelteon has the poten-tial to be the rst circadian regulator approved

by the US Food and Drug Administration forthe treatment of non-24 hour sleep-wake dis-order in the blind,” said Lockley.

“This study describes a promising newtherapy for sleep disturbances,” commentedDr. Joel Wommack, neuroscientist and re-

searcher at the University of Texas BioBehav-ioral Lab in Austin, Texas, US, during an in-terview with Medical Tribune. “More detailedstudies should be performed to establish adose-response curve and evaluate the long-term eects of this drug.”

The study was presented at ENDO 2013,the Endocrine Society’s 95th Annual Meet-ing held in San Francisco, California, US from

June 15 to 18, and was supported by VandaPharmaceuticals, which is developing ta-simelteon.


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4 August 2013 Forum

Heavy burden of viral hepatitis in the Asia

Pacific region

Excerpted from a presentation by Dr. Chen Ding-Shinn of the Department of Internal Medicine

and Hepatitis Research Center at National Taiwan University College of Medicine and

Hospital, Taipei, Taiwan, delivered at the annual conference of the Asian Pacic Association

for the Study of the Liver (APASL) recently.

The Asia Pacic region has long been

known to have a high prevalence ofviral hepatitis. Identication of bio-markers of hepatitis A, B, C, D and E hasenabled us to estimate the burden of thesehepatitides, and to implement subsequentcontrol measures. Despite tremendous suc-cesses, however, more needs to be done tocontrol viral hepatitis in our region.

Hepatitis A has one serotype and threegenotypes in humans. Genotype analysis is

very informative in investigating the mo-lecular epidemiology of hepatitis A and withthis process, we can trace the source of thevirus.

In highly endemic areas, hepatitis A in-fection usually occurs in childhood but theaected children usually remain asymptom-atic. In areas of intermediate endemicity, theinfection is acquired in late childhood or

early adulthood through person-to-persontransmission, whereas in low endemicity ar-eas, infection is seen in high-risk groups ortravelers.

With improvements in hygiene, this orallytransmied infection has decreased markedlyin the last few decades. However, this successhas resulted in an unintended consequence ofrendering a large proportion of the youngerpopulation susceptible to the virus. Fortu-

nately, eective vaccines against hepatitis Avirus are now available.

Chronic hepatitis B highly prevalentHepatitis B remains a serious problem in

the region because of highly prevalent chronic

infection that is refractory to treatment. In thepast 10 years, a series of studies mostly fromthe Asia Pacic have made it clear that thesechronic carriers are reservoirs of the infection,and are at risk of cirrhosis and hepatocellularcarcinoma, especially in those who carry highviral loads. Hepatitis B virus (HBV) genotypesalso play a vital role in the natural history andresponse to specic therapies. HBV genotypeC infection is generally worse than that seen

with genotype B. In the younger generation,the infection has been brought under control


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5 August 2013 Forum

aer mass immunization against hepatitis B

virus in early childhood.

Hepatitis C is another important cause of

morbidity and mortality in the region. The in-

fection easily becomes persistent and the chro-nicity also contributes to the development of

cirrhosis and hepatocellular carcinoma.

Although no eective immunization is

available for hepatitis C, the infection ac-

quired by parenteral route can be controlled

by preventive measures. In addition, treat-

ment with pegylated interferon plus ribavirin

for chronic hepatitis C is eective because of

the favorable genetic makeup in Asians.

Drop in hepatitis D cases

The prevalence of hepatitis D has de-

creased markedly in the last two decades and

new cases are rarely encountered now, except

in Mongolia.

Hepatitis E is endemic in limited areas of

the Asia Pacic, and travel to these areas ap-

pears to be a main risk factor for contracting

the infection, although consuming the con-

taminated foods is another important route

of the infection in some countries. While welldocumented in several countries, the epide-

miology of hepatitis E remains far from clear.

Eective vaccines have been developed but

are not yet widely available. Two recombinant

vaccines were developed and one licensed in

China in December 2011.

Conclusion

There remains a heavy disease burden of

viral hepatitis across the Asia Pacic region.

While control measures are now available,

much remains to be done. Sustained eorts

are needed from everyone including patients,

hepatologists, healthcare professionals, non-

governmental organizations and policy

makers.

READ JPOG ANYTIME, ANYWHERE. Download the digital edition today at www.jpog.com


6/35

Professor Nimish Vakiltalks about management of patients withrefractory GERD.

“Successful treatment of refractory GERDrequires thorough investigation of the patientsituation.”

Professor David Liebermanshares his perspective on the present andfuture of colorectal cancer screening.

“There is a lot of potential to preventmany cancers if we can improve the rateof CRC screening.”

Dr Markus Cornbergdiscusses the management of chronichepatitis B.

“The aim of therapy should be the cureor control of HBV infection without theneed for life-long treatment.”

In this Series, find out what these medical experts have to say about latest

updates in the management of refractory GERD, the management of chronichepatitis B and the present & future of colorectal cancer screening.

Current Opinion in

Gastroenterology

SCAN TO WATCH VIDEO

Brought to you by MIMS

MIMS Video Series featuresinterviews with leading experts.

Got a spare 5 minutes? Go to www.mims.asia/video_series

BY DOCTORS

FOR DOCTORS


7/35

7 August 2013 News

Heart patients avoid healthy lifestyles

Laura Dobberstein

Many coronary heart disease andstroke patients have not taken im-portant steps towards a healthier

lifestyle, according to a recent Canadian study.“Observational data indicate that following

an acute coronary syndrome, those who ad-here to a healthier lifestyle have a lower risk ofrecurrent events,” said lead study author Dr.

Koon Teo, of McMaster University, Hamilton,Ontario, Canada, and colleagues.

In their study, of 7,159 people who had ex-perienced stroke or coronary heart disease,81.5 percent quit smoking or never smoked,35.1 percent undertook high levels of physi-cal activity and 39 percent had healthy diets.Overall, 14.3 percent did not exhibit any of thethree recommended behaviors, 42.7 percent

displayed only one of these behaviors, 30.6percent demonstrated two behaviors and only4.3 percent had all three behaviors. Healthy

behaviors were more frequent in high incomecountries and less frequent in the lower incomecountries. The result was most pronouncedwith regards to smoking cessation.

Teo and colleagues gathered the data froman existing prospective cohort study compris-ing 153,996 adults across 17 countries between

January 2003 and December 2009.These results could help medical profession-

als enhance prevention of cardiovascular dis-ease by providing understanding of how cer-tain demographics adopt healthy behaviors.

The authors hypothesized that high-in-come countries have more strategies to pro-mote healthy lifestyle changes, particularlywhen it comes to smoking cessation. For ex-

ample, higher income countries devote moreresources to smoking cessation programs,education on tobacco and active taxation

and legislative measures than countries withlower incomes.

“Although the ndings of this study areunsurprising, this is an important study toremind ourselves – medical professionals,patients and even health care policy makers– that we are really still not doing a good job

in the area of preventive medicine,” said Dr.Tan Kok Soon, a Singapore-based cardiologistwith Mt. Alvernia Medical Centre and Park-way East Medical Centre.

Tan stressed the importance of healthy life-style choices as a major component of cardiovas-cular disease management and suggested pa-tients and doctors approach changes in diet andexercise gradually as incremental change is morelikely to be sustainable than sudden change.

“An unhealthy lifestyle usually has beenformed over a lifetime and is unfortunatelyoen pleasurable to the patient. Trying tochange this entrenched enjoyable behaviorand habit is therefore in itself very dicult,”said Tan who encourages his patients to dis-cuss their condition and lifestyle.

“Once you have established cardiovasculardisease, your risk of another event [heart at-

tack, stroke] is high. Continuing with an un-healthy lifestyle would only increase the risksubstantially,” said Tan.

Many heart patients appear to avoid healthy lifestyle options, despiteoverwhelming evidence that such lifestyle options can reduce recurrentevents.


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8 August 2013 News

Paid sick leave reduces rate of workplace

flu infections

Angeline Woon

Universal paid sick leave and access to

additional recovery days can reduce

the rate of inuenza infections in the

workplace, according to simulation models.

Researchers at the University of Pisburgh

Graduate School of Public Health (Pi PublicHealth) in the US simulated an inuenza epi-

demic using an agent-based model of Allegh-

eny County, Pennsylvania, to determine the

impact of access to paid sick days to workers.

[ Am J Public Health 2013;103:1406-1411]

The researchers found that when employ-

ees of small workplaces were given access to

universal paid sick days, workplace infections

could be reduced by as much as 5.86 percent.“The CDC [Centers for Disease Control]

recommends that people with u stay home

for 24 hours aer their fever breaks,” said lead

author Supriya Kumar (Ph.D), a post-doctoral

associate in the university’s department of ep-

idemiology. “However, not everyone is able

to follow these guidelines. Many more work-

ers in small workplaces than in large ones

lack access to paid sick days and, hence, ndit dicult to stay home when ill.”

Kumar added that if all workers are given

access to paid sick days, fewer workers would

pick up inuenza as their sick colleagues

would be more likely to stay home, thus pre-

venting workplace transmission.

Larger workforces, ie, those having 500

or more employees, usually have universal

sick days, so the reduction in transmission

was not as effective, according to the model.

For these workforces, Kumar and colleagues

looked at the impact of flu days, additional

days in which workers are encouraged to

recover from influenza at home, reducing

the potential for disease transmission at

work.

The model showed that applying a one u-

day policy could reduce workplace transmis-sion by 25.33 percent. If workers had 2 days

with which to recover, the reduction in trans-

mission rose to 39.22 percent.

“These ndings make a strong case for

paid sick days,” said Kumar. “Future research

should examine the economic impacts of paid

sick-day policies.”

The modeling system, Framework for Re-

constructing Epidemic Dynamics (FRED),used in this study was developed at Pi Public

Health, and is part of the Modeling of Infec-

tious Disease Agent Study (MIDAS) Nation-

al Center of Excellence. MIDAS is tasked to

study novel computational and mathematical

models of existing and emerging infectious

diseases.

To get the results, the researchers used

paid sick days data from the US Bureau ofLabor Statistics, standard inuenza epidemic

parameters and the probabilities of a worker

staying home when ill. They then compared

the spread of infections resulting from the ef-

fects of “presenteeism” – when an employee

goes to work despite being sick. They found

that in the simulated epidemic, the spread of

inuenza in the workplace was 11.54 percent.

Up to 72 percent of this resulted from workers

engaging in presenteeism.


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9 August 2013 News

Frequent checks of hospital patients may

do more harm

Elvira Manzano

Waking up hospital patients at night

to measure their vital signs may be

unnecessary and may actually do

more harm than good in some patients, ac-

cording to a large prospective study.

Although vital signs (blood pressure, re-spiratory rate, pulse rate, temperature) can

indicate worsening condition, routinely col-

lecting them at night in hospitalized patients

disrupts their already fragmented sleep and

causes high blood pressure and delirium, said

Dr. Dana Edelson of the University of Chica-

go in Chicago, Illinois, US and co-researchers.

Checking vital signs every 4 hours is a

common practice in many hospitals, yetthere is lile evidence to support it. Using

a simple bedside monitoring system, Edel-

son’s team studied the frequency of sleep

disruptions for vital signs monitoring and

the occurrence of adverse events (cardiac

arrests and intensive care transfers within

24 hours) among 54,096 patients admied

to their hospital from November 2008 to

August 2011( total inpatient days, 182,828).[ JAMA Intern Med 2013. doi:10.1001/jamain-

ternmed.2013.7791]

The Modied Early Warning System

(MEWS) converted each patient’s night-time

vital sign readings into a score of 0 to12, with

higher scores indicating greater risk. Median

MEWS was 2. Patients with MEWS scores of

≤1 had an event rate of 5 per 1,000 patient-

days. Those with MEWS of ≥7 had a higher

event rate at 157.3 per 1,000 patient days.

All patients had an average of two vital sign

checks per night and one disruption due to

vital sign collection 99.3 percent of the nights,

regardless of MEWS scores. Almost half of all

vital sign disruptions (45 percent) were in pa-

tients with MEWS scores of ≤1.Given these ndings, “the night-time fre-

quency of vital sign monitoring should be

reduced for low-risk medical patients to im-

prove their outcomes,” Edelson said. Leing

low-risk patients forego vital sign checks to

sleep at night would also free up nursing time

that would be beer spent on critically-ill

patients.

In an accompanying commentary, Profes-sor Sharon Inouye from Beth Israel Deacon-

ess Medical Center in Boston, Massachuses,

US, said the nding underscores the need to

readdress the widespread practice of measur-

ing vital signs frequently and recommends

that frequency of vital sign checks be tailored

to the needs and risks of every patient. Her

message to physicians and nurses: “We must

strive to recongure the hospital to provide a

restful and healing environment.”

Checking vital signs every 4 hours is a common practice in many hospitals.


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Journal ofPaediatrics, Obstetrics & Gynaecology


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11 August 2013 Conference Coverage23rd Conference of the Asian Pacific Association for the Study of the Liver 2013, June 6-10, Singapore

REVEALED: Hepatitis B viral load critical

to infection clearance

Radha Chitale

O

ut of about 400 million people withchronic hepatitis B virus (HBV), 75percent of those infected live in the

Asia Pacic region. Since HBV is stronglylinked to the development of cirrhosis andliver cancer, the infection rate constitutes asignicant public health challenge.

Risk predictors, such as the one detailedin the REVEAL-HBV* study, which trace thenatural history of chronic HBV infection, haveshown that viral load is a major predictor forclearing viral proteins.

“This risk calculator has very good calcula-tions and [is] also accurate,” said study leadDr. Chien-Jen Chen, of the Academia Sinicaand National Taiwan University in Taipei,Taiwan.

The REVEAL-HBV study was a communi-ty-based trial that included 3,087 adults withchronic HBV. Serum samples were collected at

baseline between 1991 and 1992, and duringfollow-up exams. Serum samples were tested

for HBV antigens (HBsAg and HBeAg), serumHBV-DNA, and anti-hepatitis C virus serosta-tus. [Gastroenterology 2010;139:474-482]

Over 24,892 person-years of follow-up,HBsAg seroclearance occurred in 562 partici-pants – a 2.26 percent annual seroclearancerate. The most signicant predictor of sero-

clearance were HBV-DNA levels at baseline,where a higher viral load correlated withlower seroclearance (p


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12 August 2013 Conference Coverage

Personal Perspectives

‘‘I’m particularly interested in geing new information about liverimmunology, as well as immunobiology and immunopathology, and immune

responses in the pathogenesis of chronic liver diseases. What I learned from

this meeting will be useful when I go back to my country.

Dr. Eman G. El AhwanyProfessor of Immunology, Immunology Department, Theodor BilharzResearch Institute, Egypt

‘‘The sessions are educational as most studies are from the Asia-Pacic region.We used to follow guidelines from the West, which may not be suitable for

Asians. So it’s interesting to learn novel therapies tailored for Asian patients.

Currently, there is no specic therapy for acute hepatitis B yet the new data

reported here, as well as the new agents in development, look promising.

Dr. Donald Miranda Medical Section, Endoscopy Unit, Metropolitan Medical Center and ResearchCenter, Davao City, Philippines

‘‘What’s really interesting with APASL is that we get the Asia-Pacic visionof things that we don’t usually get from the EASL. Asians have dierent

genetics and HBV genotypes, and identication of these genotypes will be

useful to understand the source of infection and to predict an individual’s

clinical outcome.

Dr. Florence HerschkeSenior Scientist, HBV Virology, Janssen Infectious Diseases (J&J), Beerse,Belgium

‘‘There are a couple of logistical problems. The venues had some issues. But thetalks have been very nice. It was really good to hear the Asian perspective onhepatitis B and C. I hope I can also network with other researchers to see howthey work and to get new ideas.

Anna Gronert AlvarezPhD Candidate, Gastroenterology, Hannover Medical School, Hannover,Germany


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Oncolytic immunotherapy promising in

sorafenib-refractory HCC

23rd Conference of the Asian Pacific Association for the Study of the Liver 2013, June 6-10, Singapore

Christina Lau

A

sian patients with advanced hepa-tocellular carcinoma (HCC) refrac-tory to sorafenib may benet from

an investigational oncolytic immunotherapyknown as JX-594, as it showed antitumor ac-tivity in a recent phase II trial.

“JX-594 consists of a vaccinia virus back- bone engineered to target solid tumors bothsystemically and locally. It is armed with thegranulocyte-macrophage colony-stimulatingfactor [GM-CSF] gene for induction of im-mune aack on cancer, and the Lac-Z gene for

monitoring,” said Dr. Jeong Heo of the PusanNational University School of Medicine, Pu-san, Korea.

JX-594 has a novel multi-pronged mecha-nism of action. It works by direct infection anddestruction of cancer cells, immune-mediatedkilling, and tumor vascular shutdown that oc-curs within 5 days of treatment. [Nat Rev Can-cer 2009;9:64-71; Sci Transl Med 2013;5:185ra63;

Cancer Res 2013;73:1265-1275]In a phase II trial of 25 Korean patientswith advanced HCC (sorafenib failure, n=20;sorafenib naïve, n=5), JX-594 demonstratedanti-tumor activity with similar response ratesin both sorafenib-refractory and sorafenib-naïve patients. [International Liver CancerAssociation Annual Meeting 2012; abstract2012-1304]

“Patients in the trial were rst treated with

an intravenous [IV] dose of JX-594, followed by intra-tumoral [IT] doses of JX-594 at weeks

1 and 3, and sorafenib from week 4,” saidHeo. “Most patients were heavily pretreatedand had extensive tumor burden at baseline.”

Response rate (RR) was 47 percent for JX-594 (IV followed by IT), increasing to 75 per-

cent when this was followed by sorafenib.Disease control rate (DCR) was 62 and 59 per-cent, respectively, for the two regimens.

“For patients failing sorafenib, RR was 43percent for IV/IT JX-594 and 80 percent for IV/IT JX-594 followed by sorafenib. DCR was 65and 59 percent, respectively,” Heo reported.

Median survival was 9.1 months for allevaluable patients and 17.3 months forsorafenib-naïve patients.

“JX-594 was well tolerated, with u-likesymptoms being the most common adverseeects,” said Heo. “Toxicities of sorafenibwere consistent with previous reports.”

More recently, Heo and colleagues con-ducted a phase II trial to determine the op-timal dose of JX-594, given by IT injection inup to 5 nodules, in 30 patients with heavily-pretreated advanced HCC (sorafenib naïve,

80 percent). [Nat Med 2013;19:329-336]“DCR at week 8 was the same for high-doseand low-dose JX-594 [47 and 46 percent],” henoted. “RR and DCR were equivalent at injectedand distant non-injected tumors at both doses.”

However, survival was signicantly relat-ed to dose (median, 14.1 months for high dosevs 6.7 months for low dose; hazard ratio, 0.39;p=0.020).

“A phase IIb trial is ongoing to investigate

the eect of JX-594 in HCC patients failingsorafenib,” he said.


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New method of grading joint damage inRA patients validated

European League Against Rheumatism (EULAR) 2013 Annual European Congress of Rheumatology, June

12-15, Madrid, Spain

Greg Town

Anew joint damage scoring method –

the ARASHI change score – has beenshown to eectively grade radio-

graphic joint damage in patients with rheu-

matoid arthritis (RA).

“Radiographic damage is directly corre-

lated to functional disability, overall severity

and pain in patients with RA,” said Dr. Isao

Matsushita from the Department of Ortho-

paedic Surgery, Faculty of Medicine, Uni-

versity of Toyama, Japan. “At present, radio-graphic damage of large joints is commonly

evaluated by Larsen grade, which has severe

limitations, including a ceiling eect within

the grade... [Our study] data highlight the

need for beer scoring and evaluation, with-

out which, progression of damage and the pa-

tient needs cannot be assessed.”

In their study, Matsushita and colleagues

validated the use of the ARASHI method inassessing hip and knee joint damage in 51

patients (mean age 59.9 years) with a diagno-

sis of RA according to American College of

Rheumatology (ACR) 1987 revised criteria*

and no history of surgical intervention. [Ab-

stract OP0015]

The researchers evaluated radiographic

(X-ray) images of 182 joints (96 hips and 86

knees) at baseline, using the ARASHI status

score, and during a 2-year period of tumor

necrosis factor (TNF)-blocker therapy with

adalimumab, etanercept or iniximab, usingthe ARASHI change score.

There are two parts to the ARASHI scor-

ing system – the ARASHI status score and the

ARASHI change score. The ARASHI status to-

tal score ranges from 0-16 points, with higher

scores representing high levels of joint dam-

age. It is based on four sub-score categories for

bone erosion (0-3 points), joint space narrow-

ing (0-3 points), joint surface (0-6 points) andstability (0-4 points). Meanwhile, the ARASHI

change total score ranges from -11-12 points,

according to sub-scores of ve categories – po-

rosis (-1-1 points), stability (-1-1 point), joint

space narrowing (-1-2 points), bone erosion

(-2-2 points) and joint surface (-6-6 points). An

increase of >1 in change score indicated joint

damage progression, while a negative score

suggests repair of joint damage.

In the researchers’ study, all the joints as-

Japanese researchers have validated the use of the ARASHI method in grading hip and knee joint damage.


15/35


BMI a good indicator of remission in RA

sessed at baseline had an ARASHI status score

ranging from 0-8 points. Of note, 100 percent

of the joints with an ARASHI status score of

3-8 points at baseline had progressive dam-

age aer 2 years of TNF-blocking therapiescompared with only 6.5 percent of those with

a baseline status score of 0-2 points (p


16/35


roids, and combination with a TNF blocker if

at least a good response according to EULAR

criteria* was not obtained.

Body weight is one of the few modi-

able factors inuencing the outcomes inearly RA patients. In early RA, obesity and

overweight are factors which are both as-

sociated with worse outcomes, ie, higher

disease activity, lower remission rates and

greater use of anti-TNF therapy, said the

researchers.

† BMI - measure of body fat dened as body mass

divided by the square of an individual’s height.

Normal weight BMI 30 kg/m2.

* EULAR response criteria: individual patients are clas-

sied as non-, moderate, or good responders, depen-

dent on the extent of change and the level of disease

activity reached.

Personal Perspectives

‘‘I I think [EULAR 2013] is very good. The key thing is that we need a forum

that brings people together, and exchanging ideas and views. I think the

great thing with EULAR is that it brings together patients and healthcare

professionals. The best way of dealing with these conditions is the multi-

professional, multidisciplinary way, with the problem in the center, the

patient and the healthcare professionals around trying to nd solutions.

Professor Anthony Woolf

Bone and Joint Decade Foundation, Truro, England

‘‘I like this congress very much. I have been to practically all EULAR

congresses so far. I like the atmosphere and the posters are very well

presented. I like the WIN [What is New] sessions, they are a wonderful

overview of what is new over the past year and also the HOT [How to

Treat] sessions. I think these are very successful and very good tracks. In my

eld of epidemiology and outcomes, I think that we have very good papers

[presented].

Professor Angela ZinkGerman Rheumatism Research Center, Berlin, Germany

‘‘ Madrid is a nice city and some very exciting studies have been presented. It is

a very good chance to interact with colleagues. It has been fantastic and great

fun.

Professor Ernest Choy

Cardi University, Wales


17/35


EULAR updates RA recommendationsLeonard Yap

The European League against Rheuma-

tism (EULAR) presented a revised ver-

sion of its rheumatoid arthritis (RA)

management recommendations.

The revised recommendations focus moreon the patient and encourage shared decision-

making between the patient and the special-

ist about the best care, said Dr. Josef Smolen,

director of the EULAR Research Center Data-

base and professor at the Division of Rheuma-

tology, Medical University of Vienna, Austria.

They outline patient treatment targets, hier-

archy of therapeutic approach (stratications

of risk) and the issue of disease-modifying an-

ti-rheumatic drugs (DMARDs) covering the

spectrum of conventional systemic DMARDs

(csDMARDs), biologic DMARDs (bD-

MARDs), targeted synthetic (tsDMARD) and biosimilars (bsDMARD).

As with the previous 2010 edition, the 2013

recommendations advocate the ecacy of cs-

DMARDS, and combination therapy as rst-

line treatment. They also regard all biologic

agents as similarly eective and safe as rst-

line therapy, Smolen said.

The update reiterates the preference for the

use of biologics in combination with metho-

trexate (MTX) rather than monotherapy. It

does not advocate the use of biologics as an

initial DMARD strategy since the treat-to-tar-

get approach will lead to similar overall out-

comes.

“These recommendations were based on

three extensive literature reviews of the e-

cacy and safety of biological and conventionalDMARDs, and address a number of common

misinterpretations of the 2010 guidelines,”

said Smolen.

“As already stated in 2010, by advocating

the use of synthetic DMARDs, rather than

biologics, as the rst-line treatment this ap-

proach avoids the over-treatment of 20 to 50

percent of patients with early RA, who will

achieve the treatment target with such initialtherapy,” he said.

Low-dose glucocorticoids should also be

considered in combination with DMARDs for

up to 6 months, but should be tapered as soon

as clinically feasible. However, in patients

failing to respond to this treatment within 6

months and when poor prognostic factors are

present, biologic DMARDs (tumor necrosis

factor [TNF]-inhibitors, abatacept or tocili-zumab – or under certain circumstances ritux-

imab) should be administered in combination

with MTX.

Patients who have failed to respond to an

initial bDMARD should receive a dierent

bDMARD. In the same manner, patients who

have failed to respond to an initial TNF-inhib-

itor may receive a dierent one, or a biologic

with an alternative mode of action. If biologic

treatment has failed, tofacitinib may be con-

European League Against Rheumatism (EULAR) 2013 Annual European Congress of Rheumatology, June

12-15, Madrid, Spain

The revised recommendations

focus more on the patient‘‘


18/35


sidered where approved.

“Although the European Medicines Agen-

cy has not approved tofacitinib hitherto, it

has been approved by the US FDA as well as

in Japan and Russia. Having weighed up theevidence, the task force is convinced of its

ecacy on clinical outcomes, function and

structure. However, until more safety data

are available and ecacy judged in clinical

practice, tofacitinib is only recommended af-

ter at least one biological has failed – in fact,

many task force members felt it should beused aer two biological treatment failures,”

he added.

Smart Rx. Every Time.

www.MIMS.com


19/35


Lifestyle intervention not shown to

reduce CV events in obese diabetics

73rd Scientific Sessions of the American Diabetes Association, June 21-25, Chicago, Illinois, US

Elvira Manzano

Alifestyle intervention program that

focuses on weight loss and exercise

helps control blood sugar and cho-lesterol in obese diabetics, according to the

updated results of the Look AHEAD* trial,

but is not eective at reducing cardiovascu-

lar events such as myocardial infarction (MI)

and stroke.

At a median follow-up of almost 10 years,

there were no signicant dierences in the

composite primary endpoints of cardiovas-

cular mortality and morbidity between pa-tients receiving lifestyle intervention and the

control group (1.83 vs 1.92 events per 100

person-years; p=0.51). [N Engl J Med 2013;

doi:10.1056/NEJMoa1212914]

Lead study author Dr. Rena Wing of the

Alpert Medical School, Brown University, in

Rhode Island, US, said several factors could

have led to the neutral eect on cardiovascu-

lar outcomes, one of which was greater useof statins in the control group. The weight

loss achieved in the intervention group may

also have been insucient to reduce the risk

of cardiovascular disease or that the educa-

tion sessions provided to the control group

diminished any between-group dierence in

the event rates.

Although there was no clear evidence of

cardiovascular benet in the trial, Wing said

some positive eects should be taken into

account. “The study shows that activity and

diet can safely reduce weight – and keep that

weight o – in patients with type 2 diabetes.”The intervention was also associated with

lower risks of kidney disease and retinopa-

thy, as reported separately by other investi-

gators at the ADA meeting. Other benets

reported during the early years of the trial

included improvement in glycemic control

and cardiovascular risk factors, reductions

in urinary incontinence, sleep apnea and de-

pression, and enhanced mobility.

The study involved 5,145 overweight or

However, changes in activity and diet can safely reduce weight.


20/35


obese patients with type 2 diabetes random-

ized to lifestyle intervention (target weight

loss 7 percent of body weight) or support and

education using conventional approaches.

Weight loss was greater (6 vs 3.5 percent)at the study’s conclusion, while blood pres-

sure and HbA1c were lower in the interven-

tion group compared with controls. The trial

was terminated early based on futility at a

median follow-up of 9.6 years.

In an accompanying editorial, Dr. Hertz-

el C. Gerstein, an endocrinologist and pro-

fessor at McMaster University and Hamil-

ton Health Sciences in Hamilton, Ontario,

Canada, said clinicians can now clearly as-

sert that changes in activity and diet safely

reduce weight as well as the need for and

the cost of medications, and can help pa-

tients achieve remission from diabetes in

some cases. [N Engl J Med 2013; doi:10.1056/

NEJMe1306987]The investigators have rearmed the im-

portance of lifestyle approaches as one of

the foundations of modern diabetes care,

Gerstein said. As for the cardiovascular out-

comes, he added that inspection of the con-

dence intervals should allow clinicians to

reassure parents that intensive lifestyle inter-

vention is unlikely to cause harm and may

provide a modest benet.

*Look AHEAD: Action for Health in Diabetes


21/35


Radha Chitale

Exercise training helps develop fat that

is more metabolically active than fat

that results from sedentary behavior,

according to two studies in mice and humans.

The resulting “good fat” can lead to metabolic

changes that improve glucose tolerance andcontrol the eects of a fay diet.

“Exercise really can train your fat,” said

lead author Dr. Kristin Stanford, a postdoc-

toral fellow at the Joslin Diabetes Center in

Boston, Massachuses, US. “Exercise train-

ing has benecial eects on subcutaneous

adipose tissue that contributes to improved

systemic glucose homeostasis.”

In the mouse study, mice were caged withor without an exercise wheel for 11 days. An

analysis of their subcutaneous adipose tissue

showed that the mice which exercised had

smaller adipose cells with less lipid in each

cell and the cells had more mitochondria,

making them “browner” – more metaboli-

cally active.

A group of 10 relatively t men who exer-

cised at high intensity 5 days per week for 12weeks showed similar changes to their subcu-

taneous white adipose tissue (SWAT) in that

it became “browner.” The men achieved at

least a 10 percent increase in maximal aerobic

capacity.

A genetic analysis of the mice and men

showed that a signicant number of genes

and metabolic pathways had changed, and

more genes changed in the fat tissue than

muscle tissue, which senior investigator Dr.

Laurie Goodyear of the Joslin Diabetes Center

and Harvard Medical School in Boston, Mas-

sachuses, said was a huge surprise.

“You don’t need a lot of exercise to cause

dramatic adaptations to subcutaneous adi-

pose tissue,” she said.

The mouse study carried on with trans-planting the trained brown fat into sedentary

mice which were given a high-fat diet. These

mice had improved glucose tolerance and

insulin sensitivity for 12 weeks of follow-up

compared with sham-treated mice.

The transplanted adipose tissue in these

sedentary mice also appeared to neutralize

the eects of a high-fat diet as there was no

dierence in body weight, and glucose levelsremained lower than those in sham-treated

mice fed normal or high-fat diets.

Stanford hypothesized that the white

adipose tissue produced secreted proteins

responsible for improvements in glucose

uptake, specically in brown adipose and

skeletal muscle tissues.

Despite the apparent success of trained fat

transplants in mice, Goodyear would not rec-ommend similar procedures in humans, say-

ing exercise was still the best way to achieve

optimal fat levels.

“I would argue that, in fact, the lack of

exercise is just as important or maybe even

more important than the increase in high-fat

feeding and increased caloric consumption

[leading to the] huge increase in rates of type

2 diabetes worldwide,” she said.

Exercise turns ‘bad’ fat ‘good’



22/35


23/35


Elvira Manzano

Daily use of basal insulin glargine inpatients with diabetes or pre-diabetesdid not increase the risk of cancer nor

did it lead to worse outcomes in a sub-analy-

sis of the ORIGIN* trial.Researchers found no dierence in the

risk of cancer among patients receiving in-sulin glargine and those given standard ofcare (hazard ratio [HR], 0.94; p=0.52). Ratesof death from cancer were also no dierentat 0.51 and 0.54 per 100 person-years, respec-tively. [Abstract 385-OR]

“Daily exposure to glargine had a neutral

eect on cancer events, including any cancer,new or recurrent cancers, cancer mortality,and subtypes of cancer,” said lead study au-thor Dr. Louise Bordeleau of McMaster Uni-versity in Hamilton, Ontario, Canada. “Thiswas not modulated by metformin or sulfonyl-urea [treatment], HbA1c levels, or weight.”

ORIGIN included 12,537 patients (meanage, 63.5 years) from 40 countries with earlytype 2 diabetes or pre-diabetes but without

active cancers and who were at high risk forcardiovascular disease. They were random-ized to one daily injection of insulin glargineor standard care, dened as clinician judg-ment with no insulin until patients were un-controlled on at least two oral diabetes drugsand annual screening for pre-diabetics, for anaverage of 6 years. The study was a 2×2 facto-rial design, with the other group randomized

to omega-3 fay acids or placebo.Results from the main trial, reported in2012, showed that glargine had no eect

on the primary endpoints of heart aack orstroke, suggesting that daily insulin to control

blood sugar levels does not accelerate cardio-vascular events. [N Eng J Med 2012;367:319-28]

In the current analysis, only 7.6 percent ofthe patients developed cancer. This translates

to 1.32 cancer events per 100 person-years for both treatment groups. Patients who experi-enced a cancer event tended to be older, becurrent or ex-smokers, have a higher frequen-cy of alcohol intake, and have had a prior car-diovascular event.

Session co-chair Assistant Professor BessieYoung of the University of Washington in Se-ale, said the new data are “very reassuring”given that there was no increase in the inci-dence of cancer among patients receiving in-sulin glargine aer over 5 years of follow-up.As insulin is a potential growth factor, therewere early concerns it may cause cancer.

As the only randomized trial to speci-cally address risk of cancer in patients receiv-ing insulin glargine vs standard care, “this isthe best evidence we have so far [that insu-lin glargine does not increase cancer risk],”

Bordeleau said.Dr. Craig Currie, an epidemiologist from

Cardi University, Wales, however, said thetrial does not adequately answer the questionof whether insulin promotes cancer in pa-tients with type 2 diabetes. “They were sayingthey used a very low dose of insulin glargine,

but they could have split it into high and lowdose to nd an association,” he said.

* ORIGIN: Outcome Reduction with an Initial Glargine

Intervention

Insulin glargine not linked to raised cancer

risk



24/35


Radha Chitale

Intense blood glucose control signicantlyreduces risks of eye, kidney and cardio-vascular diseases among patients with

type 1 diabetes mellitus (T1DM), according tothe latest results of a large, long-term studyspanning three decades.

Patients who reached an HbA1c target of 7percent had a 46 percent reduced risk of reti-nopathy (as well as lower risk of focal lasertherapy and any ocular surgery), a 39 percentreduced risk of microalbuminuria, and a 61percent reduced risk of macroalbuminuria(p


25/35


both about the eect of the therapy and about

the course of T1DM in today’s world with

contemporary therapy and the results are

very hopeful.”

Rajesh Kumar

Initial triple therapy with metformin, pio-glitazone and exenatide results in greaterand more durable HbA1c reduction com-

pared with conventional sequential add-ontherapy, and caused weight loss, rather thanweight gain, in patients with newly diagnosedtype 2 diabetes mellitus (T2DM) according toa study.

Guidelines recommend lowering HbA1cas close to normal as possible in patients withdiabetes while avoiding hypoglycemia, butno study has so far examined the optimaltherapy to achieve this goal, said the studyresearchers. They sought to compare the ef-cacy and safety of initiating triple therapy innew-onset T2DM or rst starting with metfor-min, followed by sequential addition of sulfo-nylurea and basal insulin. [Abstract: 384OR]

They randomized 147 newly diagnosed

T2DM patients (mean age, 45 years; bodymass index (BMI), 36 kg/m2; HbA1c, 8.6 per-cent; diabetes duration, 5.6 months) to receiveinitial combination therapy with metfor-min (1000→2000 mg/day) plus pioglitazone(15→45 mg/day) plus exenatide (5→10 µg/day BID) (triple therapy, n=71), or escalat-ing dose of metformin (1000→2000 mg/day)followed by sequential addition of glipizide(5→20 mg/day) and then basal insulin tomaintain HbA1c


26/35


27/35

27 August 2013 In Practice

tory of both the time scale of the condition

and its aggravating factors can help overcome

this. Looking at passive movements, func-

tional movements and activity can be greatly

benecial when deciding whether to continuewith imaging diagnostic tests.

If there are no underlying congenital chang-

es, early stage FIA is only clinically diagnos-

able and is still an area of debate, as it will not

show up on imaging. Congenital, middle and

late stages of FIA will show up on imaging

and are considered the gold standard with

MRI preferable for seeing middle stages due

to it being able to assess labral tears.

Common treatment practices

FIA is normally treated conservativelywith physical therapy to improve function

and relieve pain. Surgical intervention is of-

ten administered in more severe cases when

a patient suering from hip pain for a pe-

riod longer than 6 months tests positive on

any orthopedic special tests and for imaging

changes in anatomy. Surgery most commonly

consists of using hip arthroscopy to perform

either any or all of the following: peri-acetab-ular osteotomy, hip dislocation and debride-

ment. Aer surgery, physical rehabilitation of

the hip is benecial due to potential atrophy,

contracture or pain in returning to normal ac-

tivity.

There is a great deal of debate around cur-rent treatment practices. Surgery may be ben-

ecial in the short and mid-term, but long-

term evidence of improvement is lacking in

the scientic community. In addition, it may

be impossible for a patient to return to their

previous level of sporting activity aer sur-

gery. For this reason, GPs oen prefer the use

of anti-inammatory medication or steroid

injection as pain relief.

Treatment and prevention with osteopathy

From an osteopathic point of view, func-

tion of the hip and its supporting muscles

are a key area in both recognizing and pre-

venting FAI. As the hip is a ball and socket

joint, its structure demands a full move-

ment in a ball and socket manner within a

centered axis of movement. If the under-

lying function of the joint is not expressed

or a dysfunction movement paern is fol-

lowed for too long, it will eventually lead to

a change in the structure.

Osteopathy treatment can include pain re-

lief through so tissue techniques like mas-

sage and heat modalities, and exercises to im-

prove overall hip function.Posture, anatomical mechanics and life-

style are also considered highly relevant in

FAI treatment. An osteopath looks for any

imbalance between muscles that aid in sta-

bilizing the hip and controlling axial move-

ment by being close to the center of axis such

as psoas muscles, and those muscles that

are meant more for moving the hip but also

can inuence the hip joint, such as rectusfemoris.

A patient who exhibits

poor control of hip stabilizers

combined with increased

use of movement muscles

could alter the correct centric

control of the femoral head

due to a greater inuence

of phasic muscles on the hip

compared with tonic ones


28/35

28 August 2013 In Practice

A patient who exhibits poor control of

hip stabilizers combined with increased use

of movement muscles could alter the correct

centric control of the femoral head due to a

greater inuence of phasic muscles on the hipcompared with tonic ones.

Understanding stability vs exibility

In much the same way that instability or in-

adequate control of muscles in the shoulder are

now considered important in shoulder condi-

tions, the same consideration should be given

to the hip. Activities oen given as advice by

GPs such as swimming, yoga or cycling may

actually be poor choices of exercise for those

with FAI. Excessive instability can be a great-er problem to FIA than weight bearing. Un-

derstanding that weight bearing alone is not

the only factor in hip involvement may help a

patient get correct treatment far faster and

prevent the possibility of more serious arthrit-

ic conditions.


29/35

29 August 2013 Calendar

AUGUST

9th Singapore International Congress ofObstetrics & Gynaecology

22/8/2013 to 24/8/2013

Location: SingaporeInfo: Scientific secretariat, MIMSTel: (65) 6290 7400Email: [email protected]: www.sicog2013.com

Asia-Pacific League of Associations forRheumatology Symposium

29/8/2013 to 1/9/2013Location: Bali, IndonesiaInfo: Kenes AsiaTel: (65) 6292 4710

Email: [email protected]: www2.kenes.com/aplar/Pages/home.aspx

European Society of Cardiology Congress

31/8/2013 to 4/9/2013Location: Amsterdam, NetherlandsInfo: ESC SecretariatEmail: www.escardio.org/Pages/contactus.aspxWebsite: www.escardio.org/ESC2013

SEPTEMBER

European Respiratory Society Annual Congress

7/9/2013 to 11/9/2013Location: Barcelona, SpainInfo: ERS 2013 c/o K.I.T. GroupEmail: [email protected]: www.erscongress2013.org

Asian Pacific Digestive Week

21/9/2013 to 24/9/2013Location: Shanghai, ChinaInfo: APDWF SecretariatTel: (65) 6346 4402Email: [email protected]: www.gastro2013.org/

21st World Congress of Neurology

21/9/2013 to 26/9/2013Location: Vienna, AustriaInfo: Kenes InternationalEmail: [email protected]: www2.kenes.com/wcn/Pages/Home.aspx

49th Annual Meeting of the European Associationfor the Study of Diabetes

23/9/2013 to 27/9/2013

Location: Barcelona, SpainInfo: EASD SecretariatEmail: [email protected]: www.easd.org

13th Asian Federation of Sports MedicineCongress

25/9/2013 to 28/9/2013Location: Kuala Lumpur, MalaysiaInfo: AFSM OrganizersEmail: [email protected]: www.13afsm.com

National Skin Centre Dermatology Update 2013

26/9/2013 to 28/9/2013Location: SingaporeInfo: Mrs. Alice Chew, Conference Secretariat, NationalSkin Centre (S) Pte LtdTel: (65) 6350 8405Email: [email protected]: www.nsc.gov.sg/showcme.asp?id=149

Primary Care Forum 2013 and the 4th SingaporeHealth & Biomedical Congress 2013

27/9/2013 to 28/9/2013Location: SingaporeTel: (65) 6496 6684 / (65) 6496 6682Email: [email protected]: www.pca.sg/events

European Cancer Congress 2013 (ECCO-ESMO-ESTRO)

27/9/2013 to 1/10/2013Location: Amsterdam, NetherlandsInfo: ECCO SecretariatTel: (32) 2 775 02 01

Fax: (32) 2 775 02 00Email: [email protected]: eccamsterdam2013.ecco-org.eu/


30/35

30 August 2013 Calendar

UPCOMING

Taiwan Digestive Disease Week 2013

4/10/2013 to 6/10/2013Location: Taipei, Taiwan

Info: Congress SecretariatEmail: [email protected]: www.tddw.org

13th International Workshop on CardiacArrhythmias - Venice Arrhythmias 2013

27/10/2013 to 29/10/2013Location: Venice, ItalyInfo: VeniceArrhythmias 2013 Organizing SecretariatTel: (39) 0541 305830Fax: (39) 0541 305842Email: [email protected]

Website: www.venicearrhythmias.org

9th International Symposium on RespiratoryDiseases

8/11/2013 to 10/11/2013Location: Shanghai, ChinaInfo: MIMS, ChinaEmail: [email protected]: www.isrd.org/

18th Congress of the Asian Pacific Society ofRespirology

11/11/2013 to 14/11/2013Location: Yokohama, JapanInfo: APSR 2013 SecretariatEmail: [email protected]: www.apsr2013.jp


31/35

31 August 2013 After Hours

Rome is simply beautiful – thearchitecture, the food, the people, theweather. But a word of caution – beprepared to walk and walk and walk, as

Saras Ramiya did during her recent visit.

The entrance to the Vatican Museum is on the le; exit on the right.

Mute Swans of Peace – created in porcelain by Boehm Studios of America and pre-sented to Pope Paul VI by the Archdiocese of New York in 1976.

Inside the Vatican City. The Belvedere Apollo at the OctagonalCourt.

Gold-coated bronze sphere. Gallery of Statues and the Hall of Busts.

Musei Vaticani. Sculpture of a stag.

Mid-April is a good time to visitRome, with its dry and sunnyweather and the cool breeze. It’s

the kind of weather that made it easier forme to walk long distances without feelingtoo tired and sweaty.

And walk I did, from my B&B to the busstop, and aer a picturesque ride on the buswith glimpses of the Vatican City, from the

bus stop to the Vatican Museum. I ended upwalking in the midst of a huge crowd that

beautiful crisp sunny morning, all headedfor St. Peter’s Square.

I had booked a 2-hour guided tour of theVatican Museum in English. The guide, a

middle-aged Italian woman, gave an excel-lent explanation of Michelangelo’s master-pieces on the altar wall and ceiling of theSistine Chapel. We then proceeded on a tourof the courtyard, with its fabulous bronzeand marble sculptures produced by Greekand Roman artists and crasmen.

The sculptures were commissioned bythe earlier Popes and were made to resem-

ble the ancient Greek and Roman bronze

sculptures. There are four museums dedi-cated to the classical antiquities which in-


32/35


clude statues, group sculptures, busts, re-liefs, altars, sarcophagi, urns and mosaicsamong others.

Since bronze is more durable and flex-ible than marble, there were slight differ-ences, with the marble sculptures requir-ing more support. I liked the collectiondisplayed at the Octagonal Court whichincluded the Belvedere Apollo, River god,Laocoön, the Belvedere Hermes, PerseusTriumphant and several baths from ancientRoman baths. The antique sculptures dis-

played there aimed at bringing the Rome ofthe Caesars to life. Some of the sculptureshave been in the same place since the early1500s!

We also stopped by to admire the bronzesculptures of a pair of peacocks anking apinecone located above a fountain in whichpilgrims could wash themselves. The pea-cocks, which are thought to be part of theoriginal decoration of Hadrian’s Mausole-um circa 117-138 A.D., are notable for theirextremely ne workmanship and representimmortality.

From the courtyard, we caught glimpsesof the magnicent St. Peter’s Basilica, withits huge arrow-shaped dome. A copy of thegold-coated bronze sphere on the dome wasdisplayed in the courtyard and gave us anidea of how huge the dome is. The Vatican

Gardens and radio station could also beviewed from the courtyard.

Back inside, we toured the various gal-leries lled with more sculptures, frescoeson the ceiling and walls, as well as tapes-tries. Our guide pointed out one tapestrywhich had the eect of an optical illusion:as we walked pass it, the shape of the im-age seemed to change! I later found out thatquite a number of the tapestries on displayhad this eect owing to a unique way ofweaving.

The Raphael’s Rooms were the most col-orful with frescoes on the walls and ceil-ings. My favorite is the fresco titled ‘School

of Athens’ in the Room of the Segnatura,which was finished in 1511 and took 3years. It illustrates rational truth, one ofthe three greatest categories of the humanspirit: truth, good and beauty. In the cen-ter, Plato points upwards with a finger andholds his book Timeus in his hand, flanked

by Aristotle with Ethics; Pythagoras isshown in the foreground intent on explain-

ing the diatesseron. Diogenes is lying onthe stairs with a dish while the pessimistphilosopher Heracleitus, a portrait of Mi-chelangelo, is leaning against a block ofmarble, writing on a sheet of paper. WhenRaphael was working on these frescoes,Michelangelo was working in the SistineChapel. Euclid is on the right teaching ge-ometry to his pupils, Zoroaster is holdingthe heavenly sphere and Ptolemy is hold-ing the earthly sphere. The figure on theextreme right with the black beret is a self-portrait of Raphael.

Aer the tour, I walked to the SistineChapel. As it is a holy place, visitors arenot allowed to take photos inside. The fo-cal point of the Sistine Chapel is The LastTestament painting on the altar wall andthe ceiling artwork, which consists of nine

scenes from the Book of Genesis, of whichthe Creation of Adam is the most famous.These are the works of Michelangelo, thesculptor-turned-painter.

The more I saw, the more overwhelmedI was. I would not be surprised if the valueof the artifacts in the Vatican Museum sur-passes that of other collections in the world.(Note: The net worth of the Vatican was al-most US$1 billion in 2004, not including thevalue of the art.)

All that walking wheed my appetite,


33/35


so I headed to the cafeteria for a lunch ofpizza and cake. Aer a good rest, I headed

o to locate the post oce and buy somestamps. I also managed to get souvenirs forfamily and friends from one of the manyshops located conveniently throughout themuseum.

The tour made me realize that ‘Rome wasnot built in a day’ (pun unintended!), hence,I could not visit all the famous spots like theColosseum, Roman Forum, Spanish Steps,Trevi Fountain, etc, in a day. I told myselfthat I would return soon for a vacation.Tornerò presto! Ciao!

Tips on travel to RomeFirst, decide what you want to see and do in Rome. Draw up an itinerary and plan in advance,

especially the tour bookings to the Vatican City and museums. Do consult the weather forecast

before planning your trip. A guidebook would be handy. The main thing is to enjoy and savor

every moment in Rome like the locals do. Dolce far niente!


34/35

34 August 2013 Humor

“The results are clear and irrefutable. You are due for an autopsy!?”

“Any history of death in your family?”

“I’m afraid I’ve done all I can do.

Now it’s time for my lunch!”

“I’m sorry that you feel sodepressed. It’s probablynot a good time to talk toyou about your funeral

arrangements!”

“This crash diet of yours ...I tried it yesterday and

haven’t lost any weight!”

“I thought going to a grouphug was a nice idea!”

“Let’s see if your blood pressure is

high today. If it is, you can’t blame iton white coat syndrome!”


35/35

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fields. The information contained within should not be relied upon solely

for final treatment decisions.

© 2013 MIMS Pte Ltd. All rights reserved. No part of this publication

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Philippine edition: Entered as second class mail at the Makati Central

Post Office under Permit No. PS-326-01 NCR, dated 9 Feb 2001. Printed

by KHL Printing Co Pte Ltd, 57 Loyang Drive, Singapore 508968.

ISSN 1608 5086

medical magazine august 2013

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