medical tribune september 2013

7/27/2019 Medical Tribune September 2013

1/33

September 2013

www.medicaltribune.com

Children beer judges

of their asthma

Managing psoriasis

beyond the skin

CONFERENCE

UK osteoporosis group

updates guidelines

OSTEOPOROSIS

NEWS

AFTER HOURS

Kyoto - Japans cultural

heart

Asymptomatic AF raises stroke risk in

diabetics


2/33

2 September 2013

Asymptomatic AF raises stroke risk in

diabetics

Elvira Manzano

Clinicians should consider screening

for asymptomatic (subclinical or si-

lent) atrial brillation (AF) in type

2 diabetes patients in light of new research

showing that this underlying condition is

relatively more common and signicantly in-creases the risk of stroke in such patients.

In a cohort of 464 patients with type 2 dia-

betes, the prevalence of cerebral infarcts (as

detected by MRI) was signicantly higher in

patients with asymptomatic compared with

those without asymptomatic AF (61 percent

vs 29 percent, respectively). Similarly, stroke

events were signicantly higher in patients

with asymptomatic AF (17.3 percent vs 5.9percent, respectively; p


3/33

3 September 2013

infarcts are probably due to similar AF that

occurred in patients with silent AF before this

study.

In an editorial comment, Dr. Eric N. Prys-

towsky and Dr. Benzy J. Padanilam from St.Vincent Hospital, Indiana, US, said that as AF

is oen asymptomatic, clinicians should do

more to identify AF in diabetes patients and

carefully assess treatment strategies to pre-

serve brain function.

Stroke is the most serious complication of

AF, thus prevention is the key. More stud-ies of AF, with cerebral infarcts and stroke as

endpoints, are therefore needed, they said.

Smart Rx. Every Time.

www.MIMS.com


4/33

4 September 2013

Low vitamin D levels linked to reduced

mobility in seniors

Radha Chitale

Low vitamin D levels among the elderly

may impede mobility and increase the

diculty of performing simple, every-

day tasks, according to a new study. The nd-

ings align with a growing body of evidence

that shows how important vitamin D is for

well being as people age.

Levels of 20 ng/mL or above of 25-hy-

droxyvitamin D (vitamin D) are required for

good bone and overall health.

Seniors who have low levels of vitamin D

are more likely to have mobility limitations

and to see their physical functioning decline

over time, said lead study author Ms. Eve-

lien Sohl, of VU University Medical Center

in Amsterdam, the Netherlands. Older indi-

viduals with these limitations are more likely

to be admied to nursing homes and face a

higher risk of mortality.

Two cohorts from the Dutch Longitudinal

Aging Study Amsterdam one group aged

55-65 years (n=725) and an older group aged

65-88 years (n=1,237) were included in the

analysis. [J Clin Endocrinol Metab 2013. Epubahead of print]

Participants were assessed by six functional

metrics and the degree of diculty perform-

ing them: walking up and down stairs, dress-

ing, siing on a chair and standing again, cut-

ting toenails, walking outside for 5 minutes,

ability to transport oneself or take public

transportation.

Fiy-six percent of the older cohort and

30 percent of the younger cohort had one or

more functional limitations at baseline.

Aer adjusting for compounding factors

(age, sex, body mass index, chronic disease,

education and level of urbanization, vitamin

D deciency), subjects in the older cohort

with the lowest levels of vitamin D (30 ng/mL) (odds

ratio [OR] 1.7).

Those in the younger cohort with vitamin

D levels 30

ng/mL (OR 2.2).

Functional limitations occurred more

quickly among those in the older cohort who

were decient in vitamin D compared with

similarly decient subjects in the younger

cohort. Vitamin D deciency was associated

with more limitations aer just 3 years in the

older cohort (OR 2.0) and aer 6 years in the

younger cohort (OR 3.3).

Although the exact relationship between

vitamin D status and functional abilitiesamong the elderly is unclear, vitamin D is

known to be strongly tied to muscle health

and muscle mass and atrophy is a known risk

factor for falls, loss of function and loss of in-

dependence.

Vitamin D supplementation could pro-

vide a way to prevent physical decline, but

the idea needs to be explored further with ad-

ditional studies, Sohl said.


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5 September 2013 Forum

Europe collaboration advocating arthritis

awareness in Asia

Based on an excerpt of a presentation by Professor Anthony Woolf, chair of the Bone & Joint

Decade Foundation and coordinator of Eumusc.net, during the recent European League Against

Rheumatism (EULAR) congress held in Madrid, Spain.

A

dvancements in therapies for arthri-

tis have been very encouraging, but

the access to these therapies has been

hampered by cost and the lack of knowledgeabout these therapies. A group of experts,

healthcare professionals and health institu-

tions have collaborated to produce a set of

recommendations called How to ensure that

people with osteoarthritis and rheumatoid

arthritis (RA) receive optimal care across Eu-

rope: The European Musculoskeletal Condi-

tions Surveillance and Information Network

(Eumusc.net) Recommendations.The Eumusc.net recommendations are fo-

cused on the provision of a patient-centered

standard of care. Arthritis is very common but

there exists a relatively negative aitude that

nothing can be done to manage it. I would like

to make sure that people are aware that things

can be done and should be done to get the best

outcome. A lot of it is simple and basic like

proper diagnosis, education, general adviceabout lifestyle and how to manage their disease.

There have been various surveys on RA

across the world and there are big dierences

in disease activity in RA. Treatments are avail-

able and there are skilled doctors in these plac-

es, but there is a lack of equity in treatment. In

the European community, one of the focuses

is ensuring there is equity in outcomes. That

gives us the opportunity to try and strive for

that. It is important to get patients to under-

stand the treatment op-

tions that are available.

With this knowledge they

can go to the doctor andnot just rely on what the

doctor recommends.

The doctor, who pro-

vides that care, should be

given the right tools and

latest information; to allow

them to measure whether they are actually de-

livering adequate care to their patients. There

are many of us who cant do as much as wewould like because we are constrained by the

system that we are working in. We are quite

happy to show that we are doing not as well as

someone else because that gives us a tool, evi-

dence to go and say we really need to improve

the way we get people referred to us. We re-

ally need to improve our information services

for patients because we are behind others. In

the UK, we have been seing goals for quite awhile to drive up services.

Another important part of the Eumusc.net

project is the evidence of burden. We have

been involved in recent Lancet papers on the

global burden of disease, which has high-

lighted musculoskeletal conditions as being

far bigger in impact than anyone had ever ap-

preciated. We knew as experts, but others did

not recognize it. They underestimated how

much people themselves didnt like having

Prof. Woolf


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6 September 2013 Forum

pain and physical disability. It enables us to

show policymakers that there is a big burden

and things can be done, and this is how you

can do it.

Policymakers want solutions and also we

have to recognize that solutions should be

cost-eective. One of the barriers that we have

with RA is that it is perceived as an expensive

disease to treat. There is a concern that once

you open the door, it will be extremely costly.

We have these fancy drugs. However, a lot of

patients do extremely well on very inexpen-sive drugs if used properly. I think we should

be more public health- and health economic-

minded. We have all these wonderful medi-

cines out there but not many can aord them.

In many parts of Southeast Asia, there is no

reimbursement for the expensive drugs and

this is an enormous barrier.

I am the chair of the Bone and Joint Decade

Foundation, a global alliance of patients, pro-fessionals and scientic organizations that are

relevant to musculoskeletal health which in-

clude rheumatology, orthopedics, rehabilita-

tion and osteoporosis.

This alliance aempts to cooperate on rais-

ing the priority on musculoskeletal health

and one of the key principles of this alliance

is working to try and nd the evidence to

support advocacy and teaching people how

to advocate. For example, last year we had a

meeting in Vietnam to bring people together

and look at how we can move things forward.

This is how we get to understand the local is-sues. Clearly European standards do not al-

ways apply and we have to make them rel-

evant to the region.

We are doing a project in sub-Saharan Af-

rica, which will be applicable to many other

countries. We are training the primary health-

care worker, who works in the village, to bet-

ter recognize musculoskeletal problems and

have a positive aitude about what can bedone for their patient. This could be a sprain

or strain and how to treat it. If it looks like it

could be inammatory arthritis referring it to

someone is capable of treating it. In that way

they can go up the system and eventually get

the right level of care. It is also important to

make sure there are enough people higher

up who know how to treat more complicated

disease, initially with simple drugs like meth-

otrexate.

A lot of patients do extremely well

on very inexpensive drugs if used

properly. I think we should be more

public health- and health economic-

minded. We have all these wonderful

medicines out there but not

many can aord them


7/33

7 September 2013 News

Children better judges of their asthma than

their parents

Radha Chitale

Physicians should pay aention to what

children with asthma say about their

condition to ensure proper diagnosis

and treatment, according to an analysis of

quality of life questionnaires.

Sometimes, such surveys can show dis-agreement between childrens and parents

responses. For example, children tend to re-

port having a beer quality of life compared

with similar reports by parents, suggesting

dierences in perceived limitations due to

asthma between parent and child. [Ann Al-

lergy Asthma Immunol 2013;111:14-19]

Our research shows that physicians

should ask parents and children about the ef-fects asthma is having on the childs daily life,

said lead author Dr. Margaret Burks, of the

University of Texas Health Science Center at

San Antonio in San Antonio, Texas, US.

Parents can oen think symptoms are bet-

ter or worse than what the child is really expe-

riencing, especially if they are not with their

children all day.

Asthma is the most common chronic dis-ease among children, according to the World

Health Organization, and the disease, oen

not well managed, aects about 235 million

people worldwide.

The survey included 79 children with

asthma, aged 5-17 years, and their parents or

caregivers. The children were given the Pe-

diatric Asthma Quality of Life Questionnaire

while parents were given the Pediatric Asth-

ma Caregivers Quality of Life Questionnaire,

both of which give scores between 1-7, with a

higher number corresponding to beer qual-ity of life.

The scores were analyzed for the degree of

dierence in responses and paerns of agree-

ment with respect to factors including sex,

age and ethnicity.

Children more oen reported higher qual-

ity of life (mean 4.62) than their parents re-

ported they had (mean 3.49, p


8/33


caretakers.

The researchers recommended the follow-

ing ve areas which doctors should go over

with patients specically for an accurate read

on the eects, real and perceived, of the childscondition:

If asthma prevents the patient from playing

sports or participating in other activities

When and where asthma symptoms be-

come worse

Whether their condition aects their mood

or makes them feel dierent from their

peers

If they miss school due to asthma

If their asthma disappears

Going over these topics with young pa-

tients can help doctors gauge if the asthma

is well managed, what the triggers might be,

and if they might be depressed or feel le out.A related analysis by the same group em-

phasized that parents may be concerned over

how they appear to physicians.

Caregivers may not want to seem out of

touch with their childs day-to-day health,

and, in such fear, they may dominate the con-

versation at the oce visit, Burks said, add-

ing that insights from both parent and child

are essential.


9/33


Exercise builds strong bones in young kids

Radha Chitale

Physical activity in the form of weight-

bearing exercise may help strengthen

the bones of younger children more

so than for adolescents, a meta-analysis has

shown.

Contrary to the widely held belief that ex-

ercise is a potent stimulus to increase [bone

mineral content] and areal bone mineral den-

sity (aBMD) during childhood and youth, sig-

nicant gains could only be found in BMC of

pre-pubertal subjects, the researchers said.

That is, ecacy of training in terms of bone

mineral accrual is substantially aected by

the maturational status of subjects.

Optimal BMC can help prevent osteoporo-

sis later in life.

The data from 27 studies in which patients

participated in exercise programs that were

capable of signicantly increasing BMC and

aBMD during growth demonstrated that the

weighted overall eect size (ES) for the two

metrics increased among children who ex-

ercised compared with children not in exer-

cise programs (ES 0.17 and 0.26, respectively,

p


10/33

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11/33

11 September 2013 Conference Coverage

Transition HIV care must be safe, effective

7th IAS Conference on HIV Pathogenesis, Treatment and Prevention, 30 June-3 July, Kuala Lumpur, Malaysia

Saras Ramiya

There is a need for child to adult health-

care transition services that are safe

and eective for HIV patients, says an

expert.

Moving from pediatric to adult care, ado-

lescents may nd themselves decreasing theiradherence to medication, erratic appointment

keeping, loss of disease control and loss to fol-

low up, said Linda-Gail Bekker (Ph.D), dep-

uty director of the Desmond Tutu HIV Centre

and Associate Professor of Medicine, Univer-

sity of Cape Town, South Africa.

The Society for Adolescent Medicine in its

consensus statement in 2003 provided six crit-

ical rst steps for the transition from pediatricto adult care, besides other recommendations.

(Table 1)

The current denition of healthcare transi-

tion is the purposeful, planned movement of

adolescents and young adults with chronic

physical and medical conditions from child-

centered to adult-oriented healthcare sys-

tems. This is discussed frequently, but stud-

ied rarely, Bekker said.Barriers to healthcare transition include

inertia created by stability within the health

system; the pediatric provider may nd it dif-

cult to let go of the patients or the patients

wont allow themselves to be released from

pediatric care; the adult provider may feel

intimidated by complex patients due to lack

of expertise, time and resources; and the pa-

tients and their families may have a sense of

abandonment or loss of control in moving.

So, healthcare transition is done badly or

not at all, Bekker said. A cross-sectional study

of more than 4,000 adolescents with special

health needs showed that half had discussed

transition with a healthcare practitioner, one

third had a plan developed, but only about a

quarter had a comprehensive plan. [Pediatrics

2005;115(6):1607-12]

There are 3.4 million children under the

age of 15 living with HIV and most will live

A specic healthcare provider to be identi-ed to help with the transition.

There should be core competencies withinthe adult services to which the adolescentwas transitioning.

When possible, a portable accessible medi-cal summary should go with the adoles-cent.

There should be detailed and preferablywrien down transition plans.

The same standards of health should beoered at both the pediatric and the adultservices.

Access to services including insurance

cover.

Table 1: Six critical rst steps for child to adulttransition in healthcare.

The plan should be made with the patientand family.

Specic conditions should have specicbest practices developed.

There should be more research on out-comes.

Additional recommendations


12/33


into adulthood. Most of them live in Sub-Sa-

haran Africa and Southeast Asia. [WHO, UN-

AIDS, UNICEF. Global HIV/AIDS Response Progress Report 2011 Available at: www.

unaids.org/en/resources/publications/2011/

Accessed on 14 August] They are made up

of perinatally infected younger patients and

behaviorally infected older patients. (Table

2) Both groups need to be transitioned into

adult care.

Challenges confront young people living

with HIV as they transition from complete de-pendence on caregivers and pediatric health

services to adult HIV care systems that em-

phasize self-reliance and individual account-

ability for adherence.

With adult services perceived as intimidat-

ing and impersonal, there are reports of failed

transition with consequences of poor adher-

ence, treatment failure and loss to follow up,

Bekker said.

HIV is unique as a chronic illness becauseof social stigma, the relationship to poverty,

the fact that multiple members of one family

may be living with or have died from HIV,

and the association with sexual, intravenous

and maternal transmission.

While some resources are available and

models of transition proposed, most have

been in resourced environments, and there is

lile recognition of the need to transition ado-lescents to adult care in low- and middle-in-

come seings. Consequently, very lile pub-

lished data are available and systems to track

youth into adult care are inadequate, while

the evaluation of this process and its limita-

tions and successes are not being captured,

Bekker concluded.

Perinatally infected Sexual and injecting drug user transmission

Equal number of girls and boys. More girls than boys in Africa. More boys than girls

elsewhere.Younger. Older.

Developmental stunting. Treatment nave.

Have experienced treatment. Aware of status.

Unaware of status.

Table 2: Pediatric HIV patients.


13/33


Laws continue to marginalize key groups

of HIV patients

Saras Ramiya

R

ather than helping forward the goals

set by the international community in

slowing the spread of HIV, the current

legal and regulatory terrain is actually work-ing actively to undermine HIV prevention

and treatment projects, says an expert.

We oen imagine ourselves as having

moved away from the politics of fear and dis-

trust that characterize the early response to

the HIV epidemic. Unfortunately, this is far

from reality, said Aziza Ahmed, Assistant

Professor of Law, Northeastern University

School of Law, Boston, US.Today, a range of criminal laws contin-

ues to marginalize and stigmatize key groups

who are infected by HIV designating them as

deserving blame for spreading the virus. This

has ramications for healthcare service and

delivery, she added.

Rather than create a legal and policy envi-

ronment that facilitates disclosure of HIV and

then destigmatizes having the virus, manycountries have laws that do exactly the op-

posite. One side of these laws are those that

criminalize transmission and exposure to

HIV in other words, when a person exposes

or transmits HIV. These laws specically tar-

get people living with HIV.

The recent report of the Global Commission

on HIV and the Law found that over 60 coun-

tries worldwide criminalize exposure to HIV.

These laws have not been eective in prevent-

ing people from contracting HIV. They simplybecome a tool to further marginalize and stig-

matize individuals who are living with HIV

and further spread misinformation about the

virus, Ahmed said.

In the US, for example, in the context of

criminal trials, spiing and biting continue to

be treated as pathways for HIV transmission.

Worldwide, countries and jurisdictions

have promulgated HIV-specic criminal

laws eg, 27 countries in Africa, 14 countries

7th IAS Conference on HIV Pathogenesis, Treatment and Prevention, 30 June-3 July, Kuala Lumpur, Malaysia

Many countries have laws that undermine HIV prevention and treatmentprojects.


14/33


in Eastern Europe and Caucasus (EECA)

and 11 countries in Latin America follow the

NDjamena Model Law (2005). [Global Com-

mission on HIV and the Law, 2012. Available

at: www.hivlawcommission.org/ Accessed on15 August]

Harm reduction is another area that coun-

tries need to look at to reduce HIV trans-

mission. Harm reduction refers to policies,

programs and practices that aim primarily

to reduce the adverse health, social and eco-

nomic consequences of the use of legal and il-

legal psychoactive drugs without necessarily

reducing drug consumption. [Harm Reduc-

tion International. Available at: www.ihra.

net/what-is-harm-reduction Accessed on 15

August]

Comprehensive, consistently implemented

harm reduction without punitive approaches

in UK, Switzerland, Germany and Australia led

to HIV prevalence of less than 5 percent among

people who are injection drug users (IDUs).

In contrast, consistent resistance to harm re-

duction and punitive approaches eg, in Thai-

land and Russia resulted in HIV prevalence

of above 40 percent and 35 percent, respec-tively, among IDUs. [War on Drugs. Report of

the Global Commission on Drug Policy, 2011.

Available at: www.globalcommissionon-

drugs.org/wp-content/themes/gcdp_v1/pdf/

Global_Commission_Report_English.pdfAc-

cessed on 15 August, Lancet 2008;372:1733-45,

2010;375:1014-28]

Ahmed called upon delegates to not only

produce knowledge about the HIV epidemic,

but to accept the responsibility of creating a

legal and policy landscape that enables the

implementation of eective and high quality

HIV care, treatment, and service programs,

and does not discriminate, stigmatize, and

marginalize the very people who need sup-

port and care.


15/33

15 September 2013 Conference Coverage9th Asian Dermatological Congress, July 10-13, Hong Kong

Managing psoriasis beyond the skin

Jenny Ng

The future of psoriasis managementpoints toward a stratied individu-alized approach targeting therapies

to systemic and psychological factors oenoverlooked during treatment.

Psoriasis is not just a skin disease, said Pro-fessor Christopher Griths ofthe Universityof Manchester, England. Management of thewhole patient is paramount. Most cliniciansfail to look beyond the skin disease to bothidentify and manage associated conditions in-cluding depression, non-adherence, psoriaticarthritis and cardiovascular disease.

Evidence is accumulating on the link be-tween the severity of psoriasis and cardio-

vascular mortality. A recent Danish studyshowed an increased risk of atrial brillationand stroke, even in patients with mild psoria-sis. [Eur Heart J 2012;33:2054-2064] It is nowa question of whether early use of systemictreatments can prevent or reduce comorbidi-ties in psoriasis patients.

Good tools that can help identify variousaspects of psoriasis are necessary to guide

treatment. Recently, Griths and colleaguesdeveloped the Simplied Psoriasis Index(SPI) as a holistic approach to assess psoria-sis and beer understand the severity of thedisease. [J Invest Dermatol 2013;133:1956-1962]The SPI replaces the current PASI [Psoria-sis Area and Severity Index] scoring systemwith a composite weighted severity score de-signed to reect the impact of psoriasis aect-ing functionally or psychosocially important

body sites. In addition to current severity ofpsoriasis, it also assesses the psychosocial

impact of the disease and previous interven-tions.

Psychosocial aspects of psoriasis are im-portant for disease management and can bea signicant burden on psoriasis patients,aecting their adherence to treatment andoverall quality of life. To help patients copewith psoriasis, Griths and colleagues havedeveloped a new web-based cognitive be-

havioral therapy (CBT) program known asthe Electronic-Targeted Intervention for Pso-riasis (eTIPS), which is shown to signicantlyreduce anxiety and improve quality of life ofpsoriasis patients with similar results as face-to-face CBT. [Br J Dermatol 2013, e-pub Apr 1;doi: 10.1111/bjd.12350]

With increased understanding of psoria-sis as a disease involving both physiologicaland psychological aspects, a holistic approachof management will help improve patientsprognosis, Griths concluded.

Psoriasis management is not just about treating the skin.


16/33


Non-invasive body contouring: What works?

Christina Lau

With so many non-invasive bodycontouring devices available on themarket, choosing one that works

well requires some due diligence with respectto assessment of the scientic evidence as well

as other considerations.When evaluating a non-invasive bodycontouring device, we need to have proof ofecacy based on patient recognition of sig-nicant improvement, histologic evidence offat cell apoptosis, ultrasound or MRI conr-mation of fat reduction, and circumferencereduction for large treated areas, said Dr.Robert Weiss of the Johns Hopkins UniversitySchool of Medicine, Baltimore, Maryland, US.

Devices emiing dierent forms of radio-frequency (RF) are available for treatment ofthe abdomen, arms and legs. Unipolar RF isnot the most eective because the heating isless controllable, and there is less signicantpenetration to fat cells, said Weiss. Monop-olar RF provides deeper penetration than RF.However, bipolar RF can be used if skin tight-ening is desired because its thermal depth is

limited to a maximum of 8 to 9 mm.

To achieve skin tightening and fat reduc-tion with RF, it is important to sustain skin

temperature at about 42C for about 15 min-utes, because fat temperature is much lowerthan skin temperature, he advised. About85 percent of our patients respond to thisstrategy.

Using a dynamic monopolar RF device, an18 percent reduction in ultrasound-measuredfat thickness was achieved in the arm in pa-

tients with fat thicker than 2 cm, he added.More recently, non-thermal focused ultra-

sound has become available as the newesttechnology for non-invasive fat destruction.It provides immediate, selective and perma-nent fat cell destruction, and is safe and eec-tive for treatment of the abdomen, anks andthighs, noted Weiss.

In a study of 32 Asian patients who received

three sequential treatments with focused ul-trasound in combination with RF, reductionin MRI-measured fat thickness of 21.4 percentand 25 percent was found in the upper andlower abdomen, respectively. [Lasers Med Sci2013; e-pub Mar 24]

In Asians, results of body contouringtreatments tend to be less impressive due totheir smaller body size, thinner fat layer, anddierent dietary intake of saturated and un-saturated fat compared with Caucasians,said Dr. Henry Chan, president of the HongKong College of Dermatologists, at a pressconference held in conjunction with the con-gress. Fat thickness of 2 to 3 cm is requiredfor impressive results.

In clinical practice, accurate objective as-sessment of the degree of improvement isdicult, as patients are usually reluctant to

undergo MRI scans before and aer treat-ment, Chan added.

When evaluating a

non-invasive body

contouring device, we need

to have proof of ecacy

9th Asian Dermatological Congress, July 10-13, Hong Kong


17/33


Delusion a challenge in compulsive skin

picking

Jackey Suen

S

kin picking can be of psychiatric originthat requires a cautious approach as de-lusional patients have unshakable be-

liefs about the cause of their symptoms andare oen resistant to the idea of treatment, ac-cording to an expert from Canada.

Skin picking can result from a variety ofcauses, including underlying dermatologi-cal conditions, pruritus without rash, neu-rologic abnormalities, narcotic medications,drug abuse and psychiatric issues, said Dr.Simon Se-Mang Wong of the University of

British Columbia, Vancouver, Canada. Caseswith a psychiatric origin can be further cat-egorized into delusional and non-delusionaltypes, which require dierent treatment ap-proaches.

As delusional patients usually have un-shakeable beliefs about the cause of theirsymptoms and are oen resistant to the ideaof treatment, we need to suggest psychiatrictreatment with care, he advised. If the pa-tients are not ready for treatment, it may be

best to step away. Once they agree to starttreatment, we can prescribe antipsychotics.

Non-delusional patients are consciousof the self-induced nature of their skin pick-ing. The underlying causes are mainly de-pression, anxiety, or addiction-like picking orscratching, explained Wong. I would treatthese patients with a combination of psycho-

logical treatments and medications includingantidepressants, anxiolytics, and sometimes

low-dose antipsychotics, based on psychiatricdiagnoses.

He suggested using the Modied MiniScreen (MMS) tool to screen for depression,anxiety or delusion in patients presentingwith skin picking. Although MMS is not adiagnostic tool, it provides clues for physi-cians to decide how they should plan thetreatment.

However, other possible causes have to beruled out before a patient is diagnosed withskin picking of psychiatric origin, he added.Dermatologic conditions, such as lichenplanus and insect bites, are relatively easyto identify. For pruritus without rash, weneed to look at patients history and result ofphysical examination to decide if a full work-

up is needed to identify potential systemiccauses.

Skin picking can result from various causes.

9th Asian Dermatological Congress, July 10-13, Hong Kong


18/33


First-ever guidelines for the treatment of

non-transfusion-dependent thalassemia

18th Congress of the European Hematology Association, June 13-16, Stockholm, Sweden

Rajesh Kumar

O

ral therapy for iron chelation shouldbe initiated in non-transfusion-de-pendent thalassemia (NTDT) pa-

tients with liver iron concentrations (LIC) of>5mg Fe/g dry weight and maintained untilthey achieve levels below that threshold, ac-cording to the rst-ever guidelines for treat-ing NTDT.

Patients who achieve levels


19/33


Mini-hormone may tackle iron overload

18th Congress of the European Hematology Association, June 13-16, Stockholm, Sweden

Rajesh Kumar

Anew therapy may prove useful for thetreatment of iron overload disorders.

The cause of iron overload in dis-eases such as hereditary hemochromatosisand thalassemia is the deciency of the hor-

mone hepcidin, which regulates dietary ironabsorption and mobilization of iron fromstores.

Hepcidin deciency results in excessiveiron absorption from the diet and iron loadingof vital organs. This iron overload can lead toorgan damage and even death. Researcherssaid currently available iron chelation thera-pies are burdensome or cause side eects, cre-

ating the need for beer alternatives.Hepcidin replacement oers a potentialnew treatment for iron overload disorders.But natural hepcidin is dicult to synthesizeand has unfavorable pharmacological proper-ties.

By dening the minimal structure of hep-cidin that still retained the hormone activity,researchers developed mini-hepcidins, pep-tide mimics of the hormone, and engineered

them to improve their bioavailability and todecrease the cost of production.

Using hepcidin knockout mice as a modelof the severe form of hereditary hemochro-matosis, we demonstrated that mini-hepci-dins completely prevented iron loading ofmouse organs, said Dr. Elizabeta Nemeth ofthe University of California in Los Angeles,California, US, in a media conference.

In a mouse model of thalassemia, which ischaracterized by both anemia and iron over-load, mini-hepcidin not only prevented ironloading, but also improved anemia, said Ne-meth. Clinical trials in humans are scheduledto begin soon.

Mini-hepcidin not only

prevented iron loading,

but also improved anemia

Hepcidin replacement therapy oers a new, beer alternative to existingiron chelation therapies, say researchers.


20/33

20 September 2013 Osteoporosis

UK osteoporosis group updates guidelines

Rajesh Kumar

The National Osteoporosis Guideline

Group (NOGG) in the UK has up-

dated its clinical guidelines for the

diagnosis and management of osteoporosis

in postmenopausal women and older men.

[Maturitas 2013;75:392-396]

The update to the original 2008 document

brings an additional focus on the manage-ment of glucocorticoid-induced osteoporo-

sis, the role of calcium and vitamin D ther-

apy and the benets and risks of long-term

bisphosphonate therapy.

In all these areas, there have been new

developments over the past few years that

have had an impact on clinical practice and

require modications and/or additions to

previous guidance, the authors said.The recommendations in the guidelines

are intended to aid management decisions,

but do not replace the need for clinical judg-

ment in the care of individuals in clinical

practice.

Women with a prior fragility fracture

should be considered for treatment with-

out the need for further risk assessment al-

though BMD measurement may sometimesbe appropriate, particularly in younger post-

menopausal women, according to the up-

dated guideline.

In the presence of other clinical risk fac-

tors, the 10-year probability of a major os-

teoporotic fracture of the spine, hip, forearm

or humerus should be determined using the

WHO fracture risk assessment tool called

FRAX (www.shef.ac.uk/FRAX), using BMD if

indicated.

In those treated with glucocorticoids,

FRAX assumes an average dose of predniso-lone (2.57.5 mg/day or its equivalent) and

may underestimate fracture risk in patients

taking higher doses and overestimate risk in

those taking lower doses, wrote the authors.

Alendronate, etidronate and risedronate

are approved for the prevention and treat-

ment of glucocorticoid-induced osteoporo-

sis in postmenopausal women. Teriparatide

and zoledronic acid are approved for treat-ment of glucocorticoid-induced osteoporo-

sis in men and women at increased risk of

fracture. Bone-protective treatment should

be started at the onset of glucocorticoid ther-

apy in patients at increased risk of fracture,

they said.

The low cost of generic formulations of

alendronate makes them the rst-line option

in the majority of cases. In individuals whoare intolerant of these agents or in whom it is

contraindicated, etidronate, risedronate and

zoledronic acid are appropriate options, the

NOGG said, adding: The high cost of terip-

aratide restricts its use to those at very high

risk, particularly for vertebral fractures.

Maintenance of mobility and correction of

nutritional deciencies, particularly of cal-

cium, vitamin D and protein, should be ad-vised.

Treatment with bisphosphonates should

be reviewed every 3 years in case of risedro-

nate, ibandronate and zoledronic acid and

every 5 years for alendronate to consider a

drug holiday. If treatment has been discon-

tinued, fracture risk should be reassessed

whenever a new fracture occurs or aer 2

years irrespective of a new fracture, said the

experts.


21/33


Calcium, vitamin D reduce hip fractures

in postmenopausal women on hormone

therapy

Angeline Woon

P

ostmenopausal women on hormone

therapy seem to have reduced risk of

hip fractures if they supplement with

calcium and vitamin D, nds a US studypublished online inMenopause.

Calcium and vitamin D supplements have

been widely debated before this and recom-

mendations are in conict, such as those

made by the US Preventive Services Task

Force (USPSTF) earlier this year that said

there is no basis recommending either sup-

plementation to prevent fractures.

However, a recent analysis of the WomensHealth Initiative (WHI) project showed that

calcium and vitamin D do help, particularly

for women on hormone therapy. The inter-

action was clear between hormone therapy,

and calcium and vitamin D on hip fractures

(p interaction=0.01). The eect of calcium

and vitamin D supplementation was stron-

ger among women who also took hormone

therapy (HR, 0.59; 95% CI, 0.38-0.93) com-pared to those who took placebo (HR, 1.20;

95% CI, 0.85-1.69).

When it comes to hip fractures, the study

found that women who took both hormones

and the supplements had fewer incidences

of hip fractures (11) per 10,000 women per

year, compared to women who took hor-

mones alone (18/10,000 women/year), those

who took the supplements alone (25/10,000

women/year) and those who did not take ei-

ther (22/10,000 women/year).

Thus, taking both supplements and hor-

mones at the same time had a synergistic

eect, as taking supplements alone did not

seem signicantly beer than taking no sup-

plements and no hormones.

The authors said the results suggest thatwomen on postmenopausal hormone ther-

apy who are at normal risk for hip fracture

should also take supplemental calcium and

vitamin D.

They noted that they could not specify the

exact amount of supplementation women

in the study took calcium carbonate 1,000 mg

and vitamin D3 400 IU daily the benets

increased as supplement intake went up. Forexample, women with dietary calcium that

increased their intake to greater than 1,200

mg daily beneted strongly. Similarly, di-

etary vitamin D led to greater benets, but

as the supplements were taken at the same

time, the individual eects could not be de-

termined.

Dosage recommendations depend on

keeping side eects to a minimum eg, toomuch calcium causes constipation.

The study was a prospective, partial-fac-

torial, randomized, controlled, double-blind

trial involving WHI postmenopausal partic-

ipants at 40 centers in the US. The women

were aged 50 to 79, and were followed for a

mean of 7.2 years.

Women in one arm were randomized to

hormone therapy (n=27,347) of conjugated

estrogens alone, or conjugated equine estro-


22/33


gen plus medroxyprogesterone acetate daily.

Women in the other arm (n=36,282) received

calcium and vitamin D supplements. Both

arms were compared with placebo.

There was no interaction between either

hormone therapy or calcium and vitamin in-

take in changes to hip or spine bone mineral

density.

From the research bench to your patients bedside JPOG raises the

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

start earning CME points.

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

JPOG isNOWCME-Accredited...

in Hong Kong, Indonesia,

Malaysia and Singapore

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

peer-reviewed journal of paediatrics, obstetrics and

gynaecology in Asia. The bimonthly journal is proud to

announce its CME-accreditation in the following Asian

countries: HONG KONG, INDONESIA,

MALAYSIA and SINGAPORE.


23/33

23 September 2013 Diabetes

Individualized treatment in elderly

diabetes patients brings results

Angeline Woon

Astudy in Europe nds that seing in-

dividualized glycemic targets helps

elderly diabetic patients achieve bet-

ter HbA1c targets, with less complications.

Guidelines typically recommend seing

individualized targets to control type 2 dia-betes mellitus (T2DM) in elderly patients de-

spite the lack of evidence. The study aimed to

investigate if seing such targets will have a

positive eect, and was the rst to introduce

as well as show the feasibility of using indi-

vidualized HbA1c targets as an endpoint.

[Lancet doi:10.1016/S0140-6736(13)60995-2]

The study showed that patients with in-

dividualized treatment who received vilda-gliptin 50 mg once or twice daily as per label

(52.6 percent) were three times more likely to

reach their target than those not involved in

the study (adjusted odds ratio 3.16, 96.2% CI

1.81-5.52; p


24/33

24 September 2013 Diabetes

HbA1c of between 7.0 percent to 10.0 per-

cent, and who were aged 70 years or older.

Treatment targets were individualized

based on age, baseline HbA1c, comorbidi-

ties and frailty status. Between December 22,2010 and March 14, 2012, a validated and au-

tomated system randomly assigned patients

to either vildagliptin or placebo. The co-

primary ecacy endpoints were deemed to

be the proportion of patients reaching their

individualized, investigator-dened HbA1c

target and HbA1c reduction from baseline to

the end of the study.

Strain added that though it was a smalltrial, the results were quite dramatic and is

the rst strong evidence that individualized

care makes a huge dierence to the lives of

older people with diabetes.


25/33

25 September 2013 In Practice

Chemoprevention of breast cancer in

primary care

Dr. Wong Seng WengMedical Director & Consultant Specialist

in Medical Oncology

The Cancer Centre, a subsidiary of the

Singapore Medical Group

In the 1960s, cancer made up about 15

percent of all causes of death. Today, that

number has doubled to 30 percent. One

in three Singaporeans will develop cancer in

their lifetime and the most common cancer in

women is breast cancer.

Up to two-thirds of breast cancer cases in

women are preventable. However, this poten-

tial is largely overlooked and neglected.The population-at-risk for breast cancer is

large. In order for any breast cancer preven-

tion strategy to deliver signicant dividend,

the execution has to reach a fairly large popu-

lation. For the strategy to realistically reach a

large population-at-risk, it has to be executed

at the primary care level.

The aim of this discussion is to bring

the consideration and practice of chemo-prevention of breast cancer to the primary

healthcare scene by discussing three major

areas:

1. Clinical trial data that support chemopre-

vention of breast cancer as an evidence-

based approach;

2. Selection of patients who may benet from

chemoprevention;

3. Practical considerations in selecting treat-

ment options.

The case for chemoprevention of breast

cancer

According to Singapore Cancer Registry

data for the period 2007-2011, approximately

1,600 new cases of breast cancer are diagnosed

every year and approximately 380 deaths oc-

cur due to breast cancer yearly. This means that

about one in 16 Singaporean women will be

diagnosed with breast cancer in their lifetime.These alarming gures represent a signicant

disease burden on our society.

Estrogens promote breast cancer forma-

tion in preclinical models and in women with

naturally high levels of the hormone. Inter-

ventions that target the stimulatory eects of

estrogens on breast tissue provide an oppor-

tunity to modify breast cancer risks. To date,

clinical trials have demonstrated the ecacyof tamoxifen, raloxifene and exemestane in

reduction of the incidence of invasive breast

cancers.

Tamoxifen and raloxifene are selective es-

trogen receptor modulators (SERMs) that

exert an anti-estrogenic eect on the breast.

Treatment with tamoxifen or raloxifene for 5

years reduces the lifetime risk of breast cancer

by about 50 percent. Tamoxifen has been test-ed in both pre- and postmenopausal women

while raloxifene has only been tested in post-

menopausal women. Tamoxifen is compara-

tively more ecacious than raloxifene.

The concerns over the use of SERMS are

the associated increase in the risk of endome-

trial cancer and thromboembolic complica-

tions such as deep vein thrombosis. However,

the risks of such serious complications are

low and remain well below 1 percent. In this


26/33

26 September 2013 In Practice

aspect, the risks of endometrial cancer and

thromboembolism associated with raloxifene

are lower than that of tamoxifen. Raloxifene

has the added advantage of being indicated

for the treatment of osteoporosis.Exemestane is an aromatase inhibitor (AI)

that profoundly suppresses estrogen levels in

postmenopausal women. However, exemes-

tane is contraindicated in premenopausal

women since it may increase estrogen levels. A

clinical trial has demonstrated that treatment

with exemestane for 5 years in postmenopausal

women reduces the risk of breast cancer by 65

percent. The potential concerns over the use ofexemestane include the increased loss of bone

mass and a relative short period of follow-up

in current clinical trials. Chemopreventive tri-

als using other AIs are in progress.

The American Society of Clinical Oncology

(ASCO) guidelines last updated in 2009 rec-

ommend the use of tamoxifen and raloxifene

for breast cancer chemoprevention. The Na-

tional Comprehensive Cancer Network (USA)guidelines in 2013 consider exemestane as an

added option together with tamoxifen and

raloxifene.

Selection of patients for chemoprevention

The selection criteria used to identify pa-

tients with an increased risk for breast cancer

include:

1. Age over 60 years;2. Age over 35 years with a history of ductal

carcinoma-in-situ, lobular carcinoma-in-si-

tu, atypical ductal hyperplasia or atypical

lobular hyperplasia;

3. Age between 35 and 59 years with a Gail

model risk of breast cancer of 1.66 per-

cent over 5 years;

4. Women with known BRCA1 or BRCA2

mutations who do not opt to undergo pro-

phylactic mastectomy.

Patients in categories 2 and 4 should be

considered for referral to a specialist for as-

sessment due to higher associated risks and

the need to explore management options oth-

er than chemoprevention.

Practical considerations

Women who t the above criteria for in-

creased risk of breast cancer may benet from

chemoprevention.

For premenopausal women and postmeno-

pausal women who have undergone hyster-

ectomies, I recommend tamoxifen for 5 years.

For postmenopausal women with a uterus,either tamoxifen or raloxifene for 5 years is

an option. Doctors must consider the trade-

o between the higher anti-cancer ecacy of

tamoxifen and the higher associated risk of

endometrial cancer.

Exemestane for 5 years is an alternative

option for postmenopausal women. It has a

higher ecacy when compared with SERMs

and a lower risk of endometrial cancer andthromboembolic complications, although

long-term follow-up trial data for the drug

are still pending

Conclusion

While most breast cancer risk prediction

models are based largely on Western popu-

lations, the risk of breast cancer in Singapore

should not be ignored. There are many thera-peutic clinical trials on varying diseases upon

which Singapore doctors base treatment deci-

sions for the local population.

The increasing awareness of the threat of

cancer has raised anxiety amongst Singa-

poreans. Many are looking for non-evidence

based strategies of cancer prevention like

health supplements and folk recipes. It is time

the medical community oers them an evi-

dence-based option.


27/33

Professor Nimish Vakiltalks about management o patients withreractory GERD.

Successful treatment of refractory GERDrequires thorough investigation of the patientsituation.

Professor David Liebermanshares his perspective on the present anduture o 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 o chronichepatitis B.

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

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

updates in the management o reractory GERD, the management o chronichepatitis B and the present & uture o colorectal cancer screening.

Current Opinion in

Gastroenterology

SCAN TO WATCH VIDEO

Brought to you by MIMS

MIMS Video Series eaturesinterviews with leading experts.

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

BY DOCTORS

FOR DOCTORS


28/33

28 September 2013 Calendar

SEPTEMBER

European Respiratory Society Annual Congress

7/9/2013 to 11/9/2013Location: Barcelona, Spain

Info: ERS 2013 c/o K.I.T. GroupEmail: [email protected]: www.erscongress2013.org

London College o Clinical Hypnosis Asia

Certifcate in Clinical Hypnosis (UK University

accreditation)

21/9/2013Location: SingaporeInfo: London College of Clinical Hypnosis SecretariatTel: (65) 6809 2238 / 6557 2248Email: [email protected]

Website: www.hypnosis-singapore.com

Asian Pacifc Digestive Week

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

21st World Congress o Neurology

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

49th Annual Meeting o the European Association

or the Study o Diabetes

23/9/2013 to 27/9/2013Location: Barcelona, SpainInfo: EASD SecretariatEmail: [email protected]: www.easd.org

13th Asian Federation o Sports Medicine

Congress

25/9/2013 to 28/9/2013

Location: 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]

Website: www.nsc.gov.sg/showcme.asp?id=149

Primary Care Forum 2013 and the 4th Singapore

Health & 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 01Fax: (32) 2 775 02 00Email: [email protected]: eccamsterdam2013.ecco-org.eu


29/33

29 September 2013 Calendar

OCTOBER

Taiwan Digestive Disease Week 2013

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

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

7th International Congress o the Asian Society

Against Dementia (ASAD)

10/10/2013 to 12/10/2013Location: Cebu, PhilippinesInfo: Dementia Society of the PhilippinesTel: (632) 749 9707Fax: (632) 740 9725Email: [email protected]: www.dementia.org.ph

13th International Workshop on Cardiac

Arrhythmias - Venice Arrhythmias 2013

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

UPCOMING

9th International Symposium on Respiratory

Diseases

8/11/2013 to 10/11/2013

Location: Shanghai, ChinaInfo: MIMS, ChinaEmail: [email protected]: www.isrd.org

18th Congress o the Asian Pacifc Society o

Respirology

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

8th World Congress on Developmental Origins o

Health and Disease (DOHaD 2013)

17/11/2013 to 20/11/2013Location: SingaporeInfo: DOHaD 2013 Congress SecretariatTel: (65) 6411 6692Fax: (65) 6496 5599Email: [email protected]: www.dohad2013.org


30/33

30 September 2013 After Hours

Japans Cultural H eart

K Y O T OMonika Stiehl

The curtain rises. Dressed in a light blue

kimono covered all over with white

owers, the Maiko stands stock-still,

with head held low, turning her back to the

audience. Then the music starts. In accor-

dance with the smooth tones of the Koto,the Japanese harp, the Maiko gently begins

moving, rst elegantly her ngers and arms,

then turning to face the audience, raising the

head. The face covered with white make-up,

the lips painted aming red and the coal-

black hair artistically towered, she looks like

a piece of art.

We are in Kyoto, the cultural heart of Ja-

pan, watching the Kyomai, the so-called tra-ditional Kyoto Style Dance, performed by

a Maiko, an apprentice Geisha. Her dance

tells the melancholic story of the life of Mai-

kos and Geishas in ancient Japan. Kyoto is

the ancestral home of traditional Japanese

performances not only of the Kyomai, but

also the Chado, a Japanese tea ceremony, the

Kyogen, an ancient comic theater and the

Bunraku, a traditional puppet play.

Kyoto is rich in cultural heritage. One of

the many UNESCO world heritage sites in

the city is the Kinkaku-ji temple (or Golden

Pavilion). It shimmers in the adjacent lake

and is one of the most visited tourist spots

in Kyoto. As is the Kiyomizu-dera temple, an

ancient Buddhist shrine founded in 798. Its

present buildings were constructed in 1633.

There is not a single nail used in the entirestructure. It takes its name from the mirac-

ulous waterfall within the complex, which

runs o the nearby hills. The name Kiyo-

mizu means clear or pure water. Visitors can

drink the water, which is believed to have

wish-granting powers. The temple complex

includes several other shrines. Among them

the Jishu Shrine, dedicated to Okuninushi, a

god of love and good matches. Jishu Shrinepossesses a pair of love stones placed 6

meters apart. You can try to walk between

them and its said that you will nd love

or true love when you are able to reach the

other stone with your eyes closed. There are

always lots of young ladies and men trying

their luck.

The Ginkaka-ji temple (or Silver Pavillion)

charms with its beautiful Japanese garden.

An essential element is the impressive Zen


31/33

31 September 2013 After Hours

sand garden. The meticulously raked sand is

said to visualize the waves of the ocean and

a carefully built pile symbolizes Mount Fuji.

A relaxing stroll down Tetsugaku-no-

michi (or the so-called Philosophers way),a pleasant stone path through the northern

part of Kyotos Higashiyama district, which

is lined by hundreds of cherry blossom trees,

comes highly recommended.

Approximately 2 kilometers long, the

path begins near the Ginkaku-ji temple

and follows a small canal. The path gets its

name from one of Japans most famous and

inuential philosophers of the 20th century

Nishida Kitaro who is said to have prac-

ticed meditation while walking along it each

day to Kyoto University.

Aer all this mental food, a visit to Nishi-

ki market will provoke your appetite for real

food. Known as Kyotos Kitchen, this tradi-

tional food-market is vibrant, full of activity

and Japanese delicacies such as prawns with

teriyaki mayonnaise and stued octopus

heads served on a stick.

Kyoto has oen been described as the

most Japanese part of Japan. Here at Nishiki,

one gets the impression that this might well

be true.

Useful tips for visiting Kyoto

Visiting Kyoto requires some well thought

out pre-planning, especially if you only have

limited time. The city has an abundance of

amazing pagodas, temples and shrines to

see more than 1,800 altogether. No wonder

Kyoto has a reputation for being Japans cul-

tural heart. You will also nd graceful Gei-

shas and Maikos gliding around the corners

of the narrow streets of Gion, dressed in tra-

ditional Kimonos. You can join traditional

Japanese ceremonies like the Chado, the tea

ceremony, or the Kyomai, the Kyoto Style

Dance performanced by Maikos or Geishas,

which will make you feel like you are in an-

cient Japan. And aer that, food markets full

of Japanese specialities will bring you sud-

denly back to the present.


32/33

32 September 2013 Humor

There is no reason why you shouldnt be able to live a perectly normal lie,so long as you dont try to walk, run or eat solid oods!

The nurses are saying you are

not swallowing your pills!

Have you considered going

to a tennis court rather thana ood court?

A recent study has concluded that studies may behazardous to our health!

Are you perormingthe surgery?

The nurse in training will bewith you as soon as she isfnished catheterizing the

patient next to you!

This is the partI dread the most!


33/33

Publisher : Ben Yeo

Managing Editor : Greg Town

Contributing Editors : Christina Lau, Jacky Suen,

Jenny Ng (Hong Kong),Saras Ramiya, Leonard Yap,

Pank Jit Sin, Malvinderjit KaurDhillon (Malaysia), Dr Maria Trina

Florcruz, Dr Yves St. James Aquino(Philippines), Radha Chitale,

Elvira Manzano, Rajesh Kumar,

Grace Ling (Singapore)

Publication Manager : Marisa Lam

Designers : Razli Rahman, Charity Chan,Lisa Low, Joseph Nacpil,

Agnes Chieng, Sam Shum,Cindy Ang, Sharen Lee

Production : Edwin Yu, Ho Wai Hung,Jasmine Chay

Circulation Executive : Christine Chok

Accounting Manager : Minty Kwan

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Published by : MIMS (Hong Kong) Limited27th Floor, OTB Building,160 Gloucester Road,

Wanchai, Hong KongTel: (852) 2559 5888

Fax: (852) 2559 6910Email: [email protected]

Advertising Enquiries:

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