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PHILIPPINES

Sin Tax Law linked to lower


smoking rates in young, poor

JULY 2014

9th Congress of the

Asian-Pacific Society
of Atherosclerosis
and Vascular Diseases
&

16th Diabetes and Cardiovascular


Risk Factors

East
Meets
West Symposium

25 28 September 2014

Hong Kong Convention and Exhibition Centre

9th Congress of the

Please refer to page 19

Asian-Pacific Society
of Atherosclerosis
and Vascular Diseases
&

16th Diabetes and Cardiovascular


Risk Factors

East
Meets
West Symposium

26 28 September 2014
Hong Kong Convention and Exhibition Centre

Please
8
Pleaserefer
refer to
to page
page 4

FORUM
Retaining health
workers for a
better community

CONFERENCE
Recommendations
in the management
of HIV

MT2014-APRIL-PH.indd 1

26/3/14 11:44 am

Find out what these experts have to say about how to improve
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awareness building and the use of new therapies

Professor
Peter Ebeling

Professor
Serge Ferrari

Dr Edith Lau

Professor Bess
Dawson-Hughes

Widespread vitamin D
deficiency and low calcium
levels in Asians

Selective estrogen
receptor modulators
(SERMs), a new class of
therapy for post-menopausal
woman with osteoporosis

Treatment plans for


post-menopausal women
with osteoporosis

How aging contributes to


sarcopenia and impaired
muscle function in the
elderly

How low levels of awareness


in the public and in
healthcare professionals
affect osteoporosis care in
Asia
Benefits of fracture
registries and fracture liaison
registries (FLS) in Asia

MIMS Video Series features

interviews with leading experts

For A 5-minute Update


Go to www.mims.asia/video_series

SCAN TO WATCH VIDEO

Brought to you by MIMS

J U LY 2 01 4

Sin Tax Law linked to lower smoking


rates in young, poor
DR. LEE EDSON P. YARCIA

he Sin Tax Law reduced smoking prevalence among the younger sector and

among the poorest population, said Department of Health (DOH) acting secretary Nemesio
Gako in a press conference last May 30, 2014,
in Manila for the commemoration of World No
Tobacco Day. Together with the Department of
Finance (DOF) and World Health Organization

already see a decrease in smoking prevalence

(WHO), DOH presented results of a national sur-

among the youth and the poor, the main groups

vey showing the effectiveness of the Sin Tax Law

we aimed to protect through the law. Reducing

after a year of its implementation.

overall prevalence of smoking in the country,

The nationwide poll, conducted by the Social

however, will take some time, said DOH sec-

Weather Stations, Inc. (SWS) last March 2014,

retary Enrique Ona in a prepared statement re-

asked 1,200 Filipinos aged 18 years old and above

leased to the media.

about their smoking usage, attitudes and behav-

The insignificant changes in smoking preva-

ior after prices of cigarettes increased because of

lence among other age groups and socioeco-

higher taxes imposed by the government.

nomic classes were attributed to a shift to less

The study revealed that the prevalence

expensive cigarette brands. According to the

of smokers among those belonging to socio-

poll, 45 percent of smokers switched to cheaper

economic class E, or the poorest sector, has

brands of cigarettes when prices of cigarettes

dropped from 38 percent in December 2012 to

increased.

25 percent in March 2014. On the other hand,

The Sin Tax Law currently imposes differ-

there was a significant decline in the percent-

ent rates of taxation on high-priced and low-

age of smokers among those belonging to the

priced cigarettes, but there is a gradual pro-

18- to 24-year-old age group, from 35 percent

gression to a unitary system of taxation by

in December 2012 to 18 percent in March 2014.

2017. DOF undersecretary Jeremias Paul ex-

The overall smoking prevalence in the country

plained that this transition period is one limita-

however remained the same at 26 percent.

tion of the law in effectively changing smoking

Although weve been only a year in the im-

prevalence in the country, but he believes that

plementation of the Sin Tax law, we are glad to

once the full effect of the law is in place, smok-

J U LY 2 01 4

ers would have no option to shift brands and

smoking while they are young, said World Bank

would just quit.

country representative Dr. Julie Ann Hall.

The implementation of the Sin Tax Law is in

But Hall explained that price is just one of the

its initial stage and we are very hopeful that it

factors in tobacco control. Complementary and

will reach its goal of reducing overall smoking

equally important policy interventions, graphic

prevalence in the country as tobacco taxes con-

health warnings, must be developed by the gov-

tinuously increase each year. As of now, the Sin

ernment in order to achieve the goal of reduc-

Tax Law is already providing health benefits to

tion of smoking consumption.

Filipinos by contributing additional funds for the


implementation of DOHs Kalusugang Pangkalahatan [Universal Health Care] program, added

Sin tax revenues earmarked for health


DOH will have a computed share of PhP45.1
billion from the actual 2013 Sin Tax revenue

secretary Ona.

collections which will be used to provide for


Graphic health warnings needed

PhilHealth benefits of 14.7 million poor and

Tobacco is a killer ... You put the price to

near-poor Filipino families. The rest of the

be out of their reach, prices become so high

funds would go to enhancement of health

that they wont smoke. We have to stop them

facilities.

READ JPOG ANYTIME, ANYWHERE.


Download the digital edition today at www.jpog.com

J U LY 2 01 4

FORUM

PCP launches new health


literacy campaign

Dr. Leachon, president of the Philippine College of Physicians

recognition of poverty and low education runs

DR. MEL M. BELUAN

counter to the common myth that such diseases


uring their weekly health forum in Que-

affect only the educated and wealthy.

zon City last June 10, 2014, members of

According to Dr. Anthony Leachon, PCP

the Philippine College of Physicians (PCP) dis-

president, poverty and the other aforementioned

cussed the underlying causes of the countrys

factors prevent many Filipinos from making the

epidemic of lifestyle diseases, such as stroke,

right decisions with regards to their health. The

cancer, diabetes, hypertension, dyslipidemia,

poor are at a higher risk than the rich because

osteoporosis, chronic obstructive disease and

they have no access to preventive mechanisms

heart diseases.

[and] treatment, and, therefore, have a higher

They identified poverty, low education, poor

mortality rate, he said.

healthcare infrastructure, health manpower mal-

To address this urgent problem, the PCP

distribution, unhealthy lifestyles and a pervasive

outlined seven goals: (1) developing and dis-

curative mindset or approach to health (as op-

seminating accurate, accessible and actionable

posed to prevention) as among the significant

information about health and safety; (2) promot-

factors contributing to the worsening problem

ing changes in the health care delivery system

of non-communicable lifestyle diseases.

that improve health information, communica-

The

J U LY 2 01 4

FORUM

tion, informed decision-making and access

dubbed the Watch Your Healthstory series, are

to health service; (3) incorporating accurate,

available online. They contain information about

standards-based and developmentally appro-

preventive measures against common lifestyle

priate health and science information and cur-

diseases.

ricula in child care and education through the

Succeeding batches of videos will be re-

university level; (4) supporting and expanding

leased thereafter. This campaign builds on

local efforts to provide adult education, English

PCPs previous work of information drives. For

language instruction and culturally and linguisti-

instance, PCP had the HERO (Health Education

cally appropriate health information services in

Reform Order) Project whose objectives were to

the community; (5) building partnerships, de-

improve the healthcare system through health

veloping guidance and changing policies; (6)

education and to improve the quality of educa-

increasing basic research and development,

tion of future doctors and nurses.

implementation and evaluation of practices and

In order for the present awareness campaign

interventions to improve health literacy; and

to reach more people, the PCP encourages

lastly, (7) increasing the dissemination and use

more members of the private sector to contrib-

of evidence-based health literacy practices and

ute their resources.

interventions.

Leachon noted that before, the medical com-

Towards attaining health literacy goals, the

munity was generally averse to seeking the help

PCP launched its new health literacy campaign

of the private sector in this type of endeavors,

with the help of industry and media partners.

as this might constitute conflict of interest. We

The US Centers for Disease Control and Pre-

cannot just leave the problem to the govern-

vention defines health literacy as the degree to

ment. The private sector can fill in the gaps with

which an individual has the capacity to obtain,

the resources available to them, he added.

communicate, process, and understand basic

Leachon emphasized that education and

health information and services to make appro-

awareness drives are just one part of the advo-

priate health decisions.

cacy. Several studies show that education alone

Initially partnering with a drugstore company

does not effect concrete results. The other im-

and several pharmaceutical companies, the

portant aspect is to follow up education with

campaign will involve making videos on basic

policy-making and legislation, as exemplified

preventive health freely accessible to the public,

by the passage of the Sin Tax Law following an

especially the poor and the young. The videos,

awareness campaign.

J U LY 2 01 4

FORUM

DOHs Tayag discusses


measles elimination strategies
in the Philippines
DR. MARIA KATRINA FLORCRUZ

ticipated in that year. In 2005, it was the first


time that we did not report any confirmed case

n a special talk delivered during the plenary

of measles. It actually went to zero, remarked

session of the 51st Annual Convention of the

Tayag.

Philippine Pediatric Society (PPS), Department

However, this year, the DOH remains guard-

of Health (DOH) assistant secretary Enrique Ta-

ed due to the recent measles outbreak and the

yag shared the governments plans for measles

possibility of mortality cases due to the dis-

elimination in the country.

eases complications. To address this issue,

Tayag said that the DOH conducted rounds

the Goodbye, Tigdas campaign was initiated

of measles vaccination in the past and the ad-

in order to encourage the public to bring their

ministration of the two-dose measles-contain-

children aged 6 months to 3 years to the local

ing vaccines has been in place since 2009.

health centers for measles vaccination. The pi-

The health departments goal to eliminate

lot run of the campaign was held between Janu-

measles was initially set in 2008 but eventu-

ary 23 and February 3 of 2014 in the National

ally extended to 2015. The speaker said that

Capital Region and in several provinces of Re-

the DOH is once again moving the target to

gions 3 and IVA, noted Tayag.

2017.

Pilot runs are being done by the DOH in order

Tayag explained that between 1998 and

to get feedback and verify if the proposed strat-

2014, the cycles of mass immunization that oc-

egies or projects can work, will work and will be

curred annually or every 3 years were based on

worth it, explained Tayag. Feedback means we

the observation that there was an accumulation

learn from our mistakes, weve learned a lot

of susceptible individuals that in turn resulted

At the (DOH), mistakes are golden opportuni-

into outbreaks every 2 to 3 years.

ties to be excellent next time, he said.

If the vaccine efficacy for measles is at 90

Tayag asked for the support of the PPS

percent and the vaccine coverage is at 90 per-

members in the elimination of measles. Vac-

cent only 81 percent will be protected 19

cines will not save lives. Vaccination will save

percent will remain unvaccinated, Tayag said.

lives. Never before in the history of the DOH

For a population of 2 million children, this figure

that it had so much resource to buy these vac-

corresponds to approximately 180,000 unvac-

cines The DOH will not fail only if the Philip-

cinated children annually.

pine Pediatric Society and the Filipino com-

It was in 2004 that we did very well, thanks


to the pediatricians, thanks to all of you who par-

munity will help us stop measles for good, he


concluded.

9th Congress of the

Asian-Pacific Society
of Atherosclerosis
and Vascular Diseases
&

16th Diabetes and Cardiovascular


Risk Factors

East
Meets
West Symposium

25 28 September 2014, Hong Kong


Hong Kong Convention and Exhibition Centre
www.eastmeetswest.org.hk

Youn
Invest g
igato
Award r

Symposium Themes
t Inflammation in Atherosclerosis and Vascular Diseases
t Asia Pacific Guidelines and Management for Familial Hypercholesterolemia
and Metabolic Syndrome
t Genetics and Environmental Interaction in Atherosclerosis
t Circadian Rhythm / Sleep Disorders in Diabetes and Atherosclerosis
t The Elderly and Diabetes
t Diabetes and the Liver
t Living with Diabetes Whats New
t Infections, Diabetes and Atherosclerosis
t Nutrition and Cardiovascular Risk
t Latest Guidelines on Management of Hypercholesterolaemia and
Hypertension

Early-bird Registration
Deadline for early-bird discounted fees is 31 July 2014

Congress Secretariat

and more talks covering latest advances in the management of diabetes and
cardiovascular disease. . . . . .

MIMS (Hong Kong) Limited


27/F., OTB Building, 160 Gloucester Road

Call for Abstracts

Wanchai, Hong Kong


Tel: (852) 2155 8557

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Fax: (852) 2559 6910

Abstracts will be published in the Journal of Atherosclerosis and Thrombosis


Awards for Best Young Investigator abstracts

E-mail: info@eastmeetswest.org.hk

Organizers:

Asian-Pacific Society of Atherosclerosis


and Vascular Diseases

Hong Kong Institute of Diabetes and Obesity


The Chinese University of Hong Kong

Hong Kong Foundation for Research


and Development in Diabetes

Hong Kong Association


for the Study of Obesity

Hong Kong
Atherosclerosis Society

Asia Diabetes Foundation

MIMS (Hong Kong) Limited

J U LY 2 01 4

FORUM

Retaining health workers for a


better community
DR. YVES SAINT JAMES AQUINO
Primary health care should be delivered
through skilled and motivated human resources
for health (HRH) in achieving the goals of universal health care, said Dr. Fely Marilyn Lorenzo
of the College of Public Health, University of
the Philippines-Manila. The rationale for human
resource development should have the right
number of people, in the right place, at the right
time, with the right skills, with the right motiva-

health workforce in achieving the United Na-

tion and attitudes, at the right cost, doing the

tions millennium development goals (MDGs).

right work and under the right work conditions,

She noted that the density of health workers is

added Lorenzo.

directly proportional to the probability of survival


in vulnerable groups such as infants, children

The global picture

and pregnant patients. For example, WHO sta-

Critical shortage of health workers, defined

tistics from the last decade showed countries

relative to the needs of a country, are observed

with fewer health workers have more cases of

in 57 countries, which makes up 30 percent of

maternal mortality.

193 WHO member states. In some countries,

It is important to look at the problem glob-

there is overproduction combined with maldis-

ally and to address shortages of health workers

tribution of professionals. One example is the

worldwide. Lorenzo said that migration trend in

Philippines which produces nurses that are mal-

one country has the propensity to affect another

distributed, with areas or pockets of shortages

state. An example would be a developed coun-

even in the face of overproduction. There are

try like the US or New Zealand opening recruit-

some countries like Norway and France, where

ments for health workers, which then encourag-

there is underproduction without shortage. The

es migration of Filipino health care professionals

Philippines has a combined problem of over-

who do not have better option in the Philippines.

production, maldistribution, high out-migration,


minimal to non-existent in-migration and low return migration.
Lorenzo explained the importance of strong

The local situation


Lorenzo clarified that the critical ratio for adequate care worldwide is considered at 23 doc-

J U LY 2 01 4

FORUM

10

tors, nurses and midwives per 100,000 popula-

For professionals such as physical thera-

tion, with the mix of expertise depending on the

pists, medical technologists, pharmacist and

need.

other allied medical professionals, there are no

Fortunately were one of the few developing

standard ratio of manpower to population. Posi-

countries that are endowed with a lot of human

tions are usually limited to the institutional level

resources. We are above this critical level. We

such as hospitals, and are typically done on a

are somewhere around 30, said Lorenzo. How-

contractual or job order basis. It has become

ever, our neighbors Vietnam, Cambodia and

worse in the past few years that even doctors

Laos are below the critical level.

are also hired on a contractual basis, said Lo-

The Philippines would usually produce 45,000

renzo. In fact, when asked why nurses and doc-

to 100,000 nurses per year from 335 nursing

tors leave their posts, they usually say that they

colleges, 2,000 doctors per year from 30 medi-

have no real jobs.

cal colleges, 1,5000 midwives from 129 schools,


and 2,000 dentists per year from 31 dental

Importance of retention strategies

schools. However, the problem lies not with the

Lorenzo explained important reasons why we

number but with the distribution of health care

should retain health workers. Firstly, we need to

professionals in the Philippines. Doctors in the

recoup skill development investment by retain-

Philippines, for example, are concentrated in the

ing health workers. High turnover of profession-

National Capital Region, with the least number

als would mean losing what has been invested

in southern part of the Philippines.

on both their education and skills training. Apart

According to the Implementing Rules and

from skills development investment, other rea-

Regulation of Magna Carta for Public Health

sons include institutional memory sustainability,

Workers, there should be at least one rural

loyalty and motivation. When properly motivat-

health physician and one nurse for every 20,000

ed, long-standing health workers ensure high

residents, while there is more need for midwives

quality and continuity of care.

that should be one for every 5,000 residents.

Lorenzo stated that transformative education

In addition, there should be one rural health in-

is one of the strategies to retain health care prac-

spector for every 20,000 residents and one rural

titioners in the community. It ensures relevance,

health dentist for every 50,000 residents. Lo-

as well as high quality service and appropriate

renzo explained that the number required is not

skill mix. Recently, the global trend has been to

being followed despite the population growth in

improve education by training health workers

each municipality.

based on the needs of the community. Lorenzo

When we deplore our [municipal] and city

cited the School of Health Sciences in Tacloban

health officers for not taking care of the popu-

under the University of the Philippines as an ex-

lation, it is because they are already doing too

ample customized education where students

much, said Lorenzo.

are trained to spot schistomiasis, among other

J U LY 2 01 4

FORUM

11

things, as it is one of the most common diseas-

the ideal numbers. Although we have been im-

es in the area.

proving facilities and infrastructures, it will not

Apart from education, practice is another area


to improve retention. It helps improve working

make any difference if we dont have human


resources for health.

conditions as applied in working relationships,

It is also important to look at Asian relational

facilities and general working environment. It is

frameworks that might affect medical practice

important to recognize that young people have

locally. An example would be the ASEAN Mutu-

different demands and needs, said Lorenzo.

al Recognition Agreements, which would allow

Based on migration surveys, one of the reasons

South East Asian health professionals to prac-

for leaving cited is that workers are not happy

tice from one country to another without requir-

because they are not treated right. Profession-

ing to take the licensure exam in the receiving

als feel that people abroad are encouraged to

country. This might encourage more migration

have independent thinking or collaborative re-

out of the Philippines, which highlights the im-

lationships, which are not common views in

portance of retention strategies.

the Philippines. Relationships between doctors

Lorenzo also mentioned the importance of

and nurses and technologists are also common

maintaining competitive edge in the academe.

areas of dissatisfaction. Thus, Lorenzo empha-

She stated that based on the assessment of

sized the need to facilitate work-life balance.

university standards compared to other Asian

Young people have been noted to choose a par-

universities, many of the graduate programs in

ticular career because they see the possibility of

state universities would fail the evaluation. The

having a social life, which is difficult for a lot of

quality of education should continuously im-

the health professionals.

prove, especially with recent efforts to align the

Career progression is another way to encour-

Philippine Qualification Framework with Asian

age retention. In the Philippines, there are very

Qualification Framework. This is expected to

few institutions that implement life-long learning.

result in common educational standards with

The health care industry should follow examples

neighboring countries, allowing for common

of other scientific disciplines where workers are

assessment of skills such as independent and

given opportunities to improve their knowledge,

critical thinking, among others.

which in the long run could help improve careers and opportunities.

To conclude, Lorenzo quoted the World


Health Report 2006 on Working Together for
Health, which states that health workers save

Challenges ahead
Based on projections of human resources for various health disciplines from 2005 to
2030, Lorenzo stated that we are not meeting

lives and are in need of support and education.


Otherwise, they will leave.
That is not a threat. That is not a promise.
Its already a fact of life, said Lorenzo.

J U LY 2 01 4

CO N F E R E N C E COV E R AG E

12

Philippine College of Physicians 44th Annual Convention, 4 to 7 May 2014,


SMX Convention Center, Mall of Asia Complex, Pasay City

Rising threat of HIV in the Philippines


DR. CAROL TAN

he number of patients affected with human


immunodeficiency virus (HIV) in the Philip-

pines is increasing at an alarming rate, according to Dr. Edsel Salvaa, associate professor
with the National Institutes of Health - University
of the Philippines Manila.
From a worldwide perspective, the world has
decreased the number of new cases by 33 percent in the same time period that we increased
the number of our HIV cases by 2,667 percent,
stated the speaker.

leads to its dysregulation and collapse, causing


a decrease in the CD4 cells and the develop-

Natural history of HIV

ment of AIDS.

HIV is a retrovirus and is the causative agent

AIDS is defined as either a CD4 level less

of acquired immune deficiency syndrome

than 200, or the presence of opportunistic in-

(AIDS). It targets the T-helper cell, which is

fections regardless of CD4 levels. Opportunis-

one of the most important cells of the immune

tic infections include pneumocystis pneumonia,

system.

cryptococcus meningitis, Kaposis sarcoma, tu-

HIV has been traced to a simian virus found in

berculosis, and esophageal thrush.

chimpanzees, which probably infected hunters


through blood-borne transmission. The earliest
documented HIV infection was in the year 1959,
and the HIV epidemic occurred in the 1980s.

Changes in HIV epidemiology


Currently, the highest prevalence of HIV in
the world is still in sub-Saharan Africa. Due

Acute HIV infection results in a self-limited

to global funding, increased testing, and the

flu-like illness characterized by fever, malaise,

development of antiretroviral therapy, the

and lymphadenopathy. This is followed by a la-

number of new cases of AIDS worldwide has

tent phase, during which viral replication occurs

declined by 33 percent since 2001, and the

and causes unregulated immune stimulation.

number of deaths has declined by 30 percent

The constant stimulation of the immune system

since 2005.

J U LY 2 01 4

CO N F E R E N C E COV E R AG E

13

Traditionally, relatively few cases of HIV were

nosorbent assay (ELISA) as the screening test

found in the Philippines. However, in the year

and the Western blot method as the confirma-

2011, the Philippines became one of seven

tory test. Since ELISA has a window period of

countries that had more than 25 percent in-

three to six weeks from acute infection to devel-

crease in HIV cases. Salvaa added that in the

opment of detectable antibodies, HIV Antigen/

year 2000, there was one new HIV case detected

Antibody tests have also been developed to de-

every three days. In February 2014, there were

crease the window period to 20 days for patients

already 17 new cases detected per day.

with HIV exposure. The HIV polymerase chain

The alarming rate of increase of HIV cases


may be caused by multiple factors, explained

reaction can detect virus as early as five days


from infection.

the speaker. One important reason is the in-

The discovery of highly active antiretroviral

creasing rates of men who have sex with men

therapy (HAART) has contributed significantly

(MSM) transmission. New HIV strains have also

to decreased mortality rates of patients affected

been detected in laboratories, which were found

with HIV. Early diagnosis and timely initiation of

to be more transmissible and more aggressive.

HAART leads to better response to medications,

Improved testing may also contribute to the in-

improved life expectancy, and better quality of

creased number of HIV cases detected. Further-

life. It also reduces the risk of transmission by

more, the Philippines has the lowest condom

96 percent. Furthermore, HAART is covered by

use in Asia at 30 percent usage, making Filipi-

Philhealth, making this therapy accessible to all

nos more vulnerable to acquisition of HIV.

patients affected by HIV.


HIV does not have to be an invariably fa-

Treating patients with HIV


The speaker emphasized the importance of
early testing using HIV enzyme-linked immu-

tal disease treatment works. Weve turned HIV


from a death sentence to a chronic disease,
concluded Salvaa.

J U LY 2 01 4

CO N F E R E N C E COV E R AG E

14

Philippine College of Physicians 44th Annual Convention, 4 to 7 May 2014,


SMX Convention Center, Mall of Asia Complex, Pasay City

Recommendations in the management


of HIV
DR. CAROL TAN

the management of HIV disease and other comorbidities are being handled by primary care

he use of antiretroviral treatment has

providers.

greatly changed the epidemiology and

prognosis of patients with human immunodefi-

HIV transmission

ciency virus (HIV), according to Dr. Peter Veld-

The risk of HIV transmission is highest when

kamp, associate professor with the University

there is concomitant sexually transmitted in-

of Pittsburgh - Division of Infectious Diseases.

fection or during rape, with an average risk of

[In the United States,] the incidence is

ten percent. During vaginal intercourse, the

stable, but the prevalence is increasing, which

risk is 0.05 percent for men and 0.1 percent

means that the patients that are diagnosed with

for women. If the partner has been treated with

HIV live and stay alive, explained the speaker.

antiretroviral therapy, the risk decreases to as

The current HIV prevalence in the United

low as 0.005 percent. During receptive anal in-

States is 0.5 percent. In the Philippines, the

tercourse, the risk is at one to three percent.

over-all prevalence is 0.1 percent, but the prev-

The risk of maternal transmission to infants is

alence among men who have sex with men is

25 to 30 percent if the mother is untreated, and

7 percent.

less than one percent if the mother has been


treated. Transmission risk through percutane-

HIV throughout time


Veldkamp described three major eras of HIV.
The first is the opportunistic infection era of the

ous needle stick is 0.3 percent, while those


who share needles for intravenous drug use
incur a risk of 0.7 percent.

1980s, in which people who were diagnosed


with HIV died shortly thereafter. During this era,

HIV testing

the focus was on treatment of opportunistic in-

Indications for HIV testing include those with

fections and palliative care. Next came the an-

intravenous drug use, high-risk sexual behav-

tiretroviral era in the 1990s, wherein the focus

iors, sexually transmitted diseases, hepatitis

was the training of HIV specialists who provid-

C, tuberculosis, and hepatitis B necessitating

ed antiretroviral therapy. Since the year 2000,

treatment. Patients with thrush, vaginal candi-

we are in the chronic disease era, in which

diasis, idiopathic thrombocytopenia, seborrhe-

ic dermatitis, weight loss, failure to thrive, and


chronic diarrhea should also undergo testing.

J U LY 2 01 4

CO N F E R E N C E COV E R AG E

15

Management of HIV
The current recommended regimen for HIV

The screening test for HIV is via enzyme-

therapy includes a combination of two nucleo-

linked immunosorbent assay (ELISA). If the pa-

side reverse transcriptase inhibitors (NRTIs),

tient tests positive, confirmatory testing through

such as zidovudine and lamivudine, or teno-

western blot should be done.

fovir and lamivudine, with one non-nucleoside

Newly diagnosed HIV patients should also

reverse transcriptase inhibitor (NNRTI) such as

be tested for CD4 counts, viral load (not yet

nevirapine or efavirenz. Alternative regimens

available in the Philippines), tuberculosis,

include two NRTIs with raltegravir or two NRTIs

syphilis, hepatitis B surface antigen, cervical

with lopinavir/ritonavir.

pap smear, complete blood count, creatinine


and liver enzymes.

In the Philippines, the recommendations


are to start whenever the CD4 count is less

The speaker discussed that co-infection of

than 500. In the United States, we are a little bit

hepatitis B and HIV poses a distinct problem.

more aggressive now. You would actually start

Some drugs for hepatitis B have activity against

(treatment) whenever the patient is ready, ex-

HIV, and vice-versa. It is important to know the

plained the speaker.

HIV status before treating hepatitis B, since ex-

Referrals to HIV specialists must be done

posure of the HIV virus to a partial regimen will

whenever patients experience weight loss after

lead to resistance. It is also important to test

starting treatment, when considering switch-

for hepatitis B before treating for HIV, since HIV

ing of antiretroviral therapy, when the patient

treatment interruption or substitution can lead

is pregnant, or when there is co-infection with

to fulminant hepatitis.

tuberculosis.

J U LY 2 01 4

CO N F E R E N C E COV E R AG E

16

Philippine College of Physicians 44th Annual Convention, 4 to 7 May 2014,


SMX Convention Center, Mall of Asia Complex, Pasay City

The five essential steps in getting


ones research published
DR. PAOLO L. MENDOZA

uring a lecture at the PCPs 2014 Annual


Convention, Dr. Sera Tort, clinical editor

for the Cochrane Collaboration, discussed how


one can get his research paper published. The
following four steps were tackled.
Choose the right journal

and unbiased journal articles. Guidelines may

A key consideration is identifying the tar-

be specific to a medical specialty, locally de-

get audience, so one can be successful in in-

fined such as regional and national policies, or

forming and stimulating the right people in a

widely imposed such as the Helsinki Declara-

specific field of interest. Hence, selecting the

tion. Majority of papers conform to the IMRAD

right journal with a particular audience, either

format. Other guidelines can be adopted like

local or an international, is of utmost impor-

CONSORT, STROBE, PRISMA and STARD.

tance.

One can find resources at the website of the


EQUATOR (Enhancing the QUAlity and Trans-

Follow the instructions to authors

parency Of health Research) Network which is

Every journal has its own set of instructions

a worldwide initiative to improve the reliability

or guidelines for writers. Guidelines can be se-

and value of published health research litera-

lective and may not be comprehensive. Check-

ture.

lists are provided by some publications to facilitate submission. The most common reason for
manuscripts not being accepted is failure to follow the instructions, said Tort.

Create your team


People significantly involved in the research
are encouraged to participate in the writing.
Rules on authorship should have been agreed

Consider other guidelines


Many recommendations worldwide have
been updated to better create accurate, clear,

at the outset. Everyone involved should decide


and agree on level of involvement, designated
responsibilities and timetable.

J U LY 2 01 4

Preparing your manuscript

CO N F E R E N C E COV E R AG E

17

to replicate the study. Statistical analysis meth-

The more you work on the outline, the easier

ods, references and ethical statements are men-

it will be to get your paper done, said Dr. Tort.

tioned. Study results, and figures and tables are

Data and references should be carefully verified

excluded.

and other authors should be acknowledged.

Results and analysis. Tort advised that the

The outlines level of detail should be from sim-

most important findings should be presented

ple to thorough. The outline is then converted to

first. Information should be written concisely,

a first draft. A suggested sequence for writing is

clearly and efficiently. The tables and figures are

methods and results first, followed by introduc-

described briefly, ensuring what is reported in

tion, discussion and finally abstract. One can

them is not repeated in the text. Conclusions are

use software programs such as Copyscape to

excluded.

help check for references and avoid plagiarism,

Discussion. Conclusions are based on evidence. Key findings are summarized first (re-

whether intentional or unintentional.


Title. It should be clear and concise. Some

sults should not be repeated; no new data

guidelines require that information about the

should be added). Strengths and weaknesses

study design be included in the title.

of the study should be identified. Clinical and

Abstract. A good abstract should be clear

statistical significance should be distinguished.

and complete, reflecting the essence of the ac-

Results should be compared with similar stud-

tual manuscript. The author and editor should

ies. Emphasis should be placed on clinical and

review and revise to ensure that information is

future research implications.

consistent in both places. Oftentimes, the abstract is the only section that is read. Careful

Other tips

keyword selection will make it more accessible

Check spelling and grammar.

on the Internet.

Request a colleague to review the manu-

Introduction. It should provide a background


of the study. This is the section where one can
review

literature, state study rationale,

and

post a hypothesis. Around 500 words will suffice but always check the journals instructions

script.

Ensure that the references follow the required format.
Ensure that references cited in text appear
in the bibliography.

to authors. Do not copy previous material. Do

Carefully choose the papers title.

not summarize results.

Do not submit the paper to several journals.

Methods. This section is where one states

Check online resources (eg, INASP has the

how and why a study was done in a particular

website http://www.authoraid.info/en/ to help

way. There should be enough detail for readers

researchers publish their papers).q

5th 5-Continent-Congress
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Klaus Fritz (Germany)
Sahar Ghannam (Kuwait)
Chee-leok Goh (Singapore)
Michael Gold (USA)
David Goldberg (USA)
Mitchel Goldman (USA)
Merete Haedersdal (Denmark)

Laser
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Moshe Lapidoth (Israel)
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Woraphong Manuskiatti (Thailand)
Vic Narurkar (USA)
Kei Negishi (Japan)
Stuart Nelson (USA)
Peter Peng (Taiwan)
Flora Xiang (China)

5th 5-CONTINENT-CONGRESS
CONGRESS PRESIDENT

Chi-keung Yeung (Hong Kong)

Henry Chan (Hong Kong)

Robert Weiss (USA)

5-CONTINENT-CONGRESS
BOARD MEMBERS
Maurice Adatto (Switzerland)
Christine Dierickx (Belgium)
Klaus Fritz (Germany)
Michael Gold (USA)
David Goldberg (USA)
Moshe Lapidoth (Israel)

J U LY 2 01 4

CO N F E R E N C E COV E R AG E

19

Philippine College of Physicians 44th Annual Convention, 4 to 7 May 2014,


SMX Convention Center, Mall of Asia Complex, Pasay City

HIV pharmacotherapy review


DR. JAMES SALISI

he recent spike in the number of new


cases of human immunodeficiency virus

(HIV) infection in the Philippines means that


clinicians and pharmacists alike may need to
increase their awareness and competency in
prescribing and monitoring HIV treatment.
Although taught in medical and pharmacy

What is antiretroviral therapy (ART)?

schools, the scarcity in exposure to clinical

Antiretrovirals are a class of drugs that target

cases before highlights the need to for physi-

vital steps in HIVs cell replication cycle. Studies

cians and pharmacist to review HIV pharma-

have proved that this is the most effective strat-

cotherapy in order to cater to the increasing

egy for treating HIV infection among the avail-

HIV patient population.

able options today.

I agree with everything that has been said

In general the idea with antiretroviral therapy

about how important it is for primary care doctors

is that we are going to choose agents from differ-

to be part of treating HIV. Especially as patients

ent classes that will be able to target vital steps

live longer learning and having experienced

in the cell replication cycle. So, rather than hav-

managing chronic conditions such as diabetes

ing just one way to focus on the virus, it helps in

and cardiovascular diseases in the context of

reducing the risk of resistance if we can target

HIV infection is very important, said Dr. Lauren

more than one step, said Jonkman.

Jonkman, an instructor and primary care clinical pharmacist from the School of Pharmacy of

Six classes of ART

the University of Pittsburgh during the PCPs

There are six classes of antiretroviral drugs

44th Annual Convention. Her talk focused on

approved in the United States. These drugs tar-

the most common and clinically relevant ad-

get specific steps in the replication of the cell

verse drug reactions to first-line antiretrovirals.

and are called (1) nucleoside reverse transcrip-

She also talked about how to evaluate common

tase inhibitors (NRTIs), (2) protease inhibitors

and clinically relevant drug interactions between

(PIs), (3) non-nucleoside reverse transcriptase

antiretrovirals and other primary care medica-

inhibitors (NNRTIs), (4) fusion inhibitors, (5)

tions.

CCR5 inhibitors and (6) integrase inhibitors.

J U LY 2 01 4

CO N F E R E N C E COV E R AG E

20

Four of these antiretrovirals are available in the

have co-morbidities such as diabetes, tubercu-

Philippines NRTIs, NNRTIs, PIs and integrase

losis , iron deficiency anemia. The choice of ap-

strand transfer inhibitors (ISTIs).

propriate regimen to start the patient requires

In the Philippines, the ARTs that are available

knowledge of the properties of each drug and

are zidovudine, stavudine (obsolete), lamivu-

their known side effects. To illustrate this prin-

dine and tenofovir for NRTIs; two NNRTIs, efa-

ciple, Jonkman presented four clinical cases of

virenz and nevirapine; one protease inhibitor,

HIV pharmacotherapy (below).

lopinavir/ritonavir; and raltegravir for ISTI.

Factors that increase risk of side effects include


gender (female > male), additive effects from

ART regimens
There are three ART regimens for HIV treat-

concomitant medicines, drug-drug interactions,


genetic variations and co-morbid conditions.

ment: NNRTI, PI and INSTI Regimen. What


they have in common is the combination of two

Example cases

NRTIs, either zidovudine and lamivudine or te-

Case 1 is about a 33-year-old female with

nofovir and lamivudine. Whats different is the

CD4 count of 300 and is to be started on ART.

third drug added to the NRTI such as PI and IN-

Her past medical history includes active TB cur-

STI. For example, nevirapine or efavirenz for the

rently undergoing anti-TB treatment, iron de-

NNRTI regimen, lopinavir/ritonavir for PI regi-

ficiency anemia, and type I diabetes. Because

men and raltegravir for INSTI regimen.

of her gender, CD4 count, concomitant medications and co-morbidities, the most appropriate

Adverse events, non-adherence and treat-

regimen for her would be tenofovir/lamivudine

ment failure

plus efavirenz.

As a pharmacist I always think about adverse

To understand this choice, Jonkman dis-

effects and the side effects that patients start to

cussed the different side effects and peculiari-

notice with the drugs. These side effects are es-

ties of ARTs. NRTIs generally undergo renal

pecially important in HIV. If patients feel some

adjustment and have no cytochrome P-450 iso-

sort of side effects and feel that the medicine is

enzyme interactions. This means that clinicians

hurting them in some way especially if you are

must consider the additive effects of other medi-

talking about patient with CD4 counts that are

cines such as vincristine, cisplatin and isoniazid

not very low and feeling okay. The likelihood of

that cause additive peripheral neuropathy, and

somebody stopping their medicine is fairly high

ganciclovir that causes additive bone marrow

and that non-adherence can lead to treatment

toxicity.

failure, Jonkman explained.

NRTI class toxicities include lactic acidosis,

Being aware of factors that can increase risk

peripheral neuropathy, pancreatitis and lipodys-

for adverse events will help in deciding appropri-

trophy. Zidovudine can cause anemia/myelo-

ate treatment for patients especially those who

toxicity, headache and nausea. Lamivudine is

J U LY 2 01 4

CO N F E R E N C E COV E R AG E

21

active against hepatitis B and may exacerbate

should not be given with rifampicin, voricon-

the condition if discontinued. Tenofvir can cause

azole, immunosuppressants, anticonvulsants,

tubular nephropathy and is also active against

statins, etc.

hepatitis B. Although stavudine is not used any-

In addition to drug interactions, primary

more to initiate therapy, it can cause lipoatrophy,

health care workers must also be watchful of life

peripheral neuropathy and acidosis.

adjustments that could trigger non-adherence

NNRTIs on the other hand are metabolized

to medication such as in case 4 which describes

through CYP3A4 and 2B6. These classes of

a 25-year-old male who has been taking nevir-

drugs interact with rifampicin. Adherence is es-

pine with zidovudine/lamivudine for the past two

pecially important since a single mutation can

years. A year ago, his CD4 count was 600. He

confer resistance to entire class. Nevirapine

comes to the clinic complaining of weight loss

is contraindicated in CD4 of more than 250 in

and fatigue over the past 2 months and reports

women and more than 400 in men. Patients on

that he has been working at a call center for

this drug may experience rash and hepatitis. Efa-

about four months already. The symptoms may

virenz may cause dizziness and vivid dreams,

also be brought about by new-onset TB, drug

which diminish over time. It can also cause rash

resistance and virologic failure, anemia and

and is potentially teratogenic.

non-adherence.

On to case 2. Take the patient in case 1 and


instead of type 1 diabetes, she now has schizo-

Strategies to improve adherence

phrenia. In order to be on the safe side, primary

Closely monitoring the patient during the

care physicians would be better off referring this

first months of treatment, using multidisciplinary

patient to an HIV or infectious diseases specialist.

approach, assessing adherence at every clinic

Case 3 describes a 29-year-old male with a

visit, providing resources for patients and iden-

CD4 count of 355 who was started on tenofovir

tifying reasons for non-adherence may help the

and lamivudine. He has a history of severe de-

patient adhere to his medications.

pression and a past suicide attempt. He devel-

In summary, adverse reactions to ART is com-

oped a severe rash after 1-week of treatment.

mon but most effects resolve with time. Primary

In his case, the rash was from nevirapine and

care physicians and pharmacists should en-

this should be changed to lopinavir/ritonavir. Ad-

courage patients to push through mild, consti-

dtionally, the patient is a good candidate for dis-

tutional side effects. Lastly, reviewing drug-drug

cussion with an HIV/ID specialist.

interactions for all patients on PIs and NNRTIs,

Primary care physicians and pharmacists

especially rifampicin and other CYP34A induc-

should be aware of drug interactions especially

ers and substrates will help avoid side effects

in HIV therapy. For example, protease inhibitors

that may induce non-adherence.

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J U LY 2 01 4

F E ATU R E

23

Conflict of interest in the practice


of medicine
DR. LEE EDSON P. YARCIA

cardiologist who is a part-owner of the laboratory in a polyclinic where he practices

routinely orders baseline lipid profiles and electrocardiogram for all his hypertensive patients
during their first consult. Is the doctor in a conflict of interest?
Dr. Guia Crisostomo Tan, bioethics expert and
ENT consultant with The Medical City, posed
this question during the 44th Annual Convention
of the Philippine College of Physicians held last

by physicians of gifts, hospitality trips, and sub-

May 4-7 2014 at SMX Convention Center, Pasay

sidies of all types from health care industry that

City, as she discussed the issue of conflict of in-

might diminish, or even appear to others to di-

terest in the medical community.

minish, the objectivity of professional judgment.


As documented by some studies, the accep-

Conflict of interest defined


The World Medical Association says conflict
of interest is understood to exist when profes-

tance of even small gifts can affect clinical judgment and heighten the perception and/or reality
of a conflict of interest, states the ACP-ASIM.

sional judgment concerning direct patient care

The Philippine College of Physician, on the

might be duly influenced by secondary interest.

other hand, identifies fee-splitting as a form of

In the scenario introduced above, a physi-

conflict of interest. Fee-splitting is a practice

cians ownership in facilities to which he refers

whereby a physician receives a financial return

his patients does in fact constitute a conflict of

- either in the form or a compensation, incentive

interest. This is because a secondary interest,

from another individual or institution, fees that

in the form of increased income from increased

are outside of professional fee as a result of a

services, creates a tension between the physi-

referral or co-management. This practice, where

cians primary interest in their patients welfare

the interest of the patient becomes secondary

and secondary interest of personal gain.

to economic gain, is not allowed by the society.

The American College of Physicians-Amer-

Other areas where conflicts of interest might

ican Society of Internal Medicine (ACP-ASIM)

arise include self-referral, drug dispensing in the

extends the concept to include the acceptance

clinic, commissions, gifts or any personal ben-

J U LY 2 01 4

F E ATU R E

24

efit, speaking engagements and research for

physician may be involved in organizations or

pharmaceutical companies by physicians, gate-

enterprises including drug industries as a re-

keeping functions such as that of HMO coor-

sult of which, there are conflict in interest that

dinators, holding administrative functions, and

involve the best interest of the patients. Physi-

endorsement of consumer products.

cians should be transparent in his relations with


organizations and enterprises. In particular, he

Are all conflicts of interest unethical?


Dr. Tan explained that secondary interests

should be especially careful to remain faithful to


his primary duty to his patient.

are observed in areas where one has financial,


administrative, academic or even emotional
interests.

External regulations from the government


Conflicts of interest are recognized even out-

The challenge among the medical commu-

side the medical community. The United States

nity is to recognize that conflicts of interest do,

government has instituted measures to regulate

in fact, exist. Oftentimes, doctors deny being in-

it. Federal law prohibits physicians from refer-

fluenced by external factors in their patient care.

ring Medicare or Medicaid beneficiaries to des-

This is where it becomes unethical, when there

ignated health services if the physicians or their

is a general denial that the problem exists.

immediate family members have ownership or


investment interests in the entities or have com-

Guidelines by medical societies on conflict


of interests

pensation arrangements with the entities.


Centers of Medicare and Medicaid Services

In recent times, there had been a number of

require physicians to disclose to patients the

medical groups who have released guidelines

physicians ownership of or investments in hos-

in relation to conflict of interest. The American

pitals. The Medicare Payment Advisory Com-

Medical Association Council of Ethical and Ju-

mission recommended that Congress require

dicial Affairs issued guidelines for interactions

hospitals and other entities that bill Medicare to

with the pharmaceutical industry. The Phar-

report physician ownership interests (direct and

maceutical and Healthcare Associations of the

indirect) and that this information be posted on

Philippines Code of Ethics also mentions about

a public website.

conflict of interests. The International Federation

The Asia-Pacific Economic Cooperation has

of Pharmaceutical Manufacturers and Associa-

published the Mexico City Principles for Voluntary

tions (IFPMA) code of ethics has expanded be-

Codes of Business Ethics in the Biopharmaceuti-

yond marketing practices to cover interactions

cal Sector, which promulgates a set of principles

with healthcare professionals, medical institu-

that address conflicts of interests.

tions and patient organizations.


Locally, the Philippine Medical Association
in the Code of Ethics 2006 recognized that the

Reasons for conflict of interest


The unethical practice that arises from con-

J U LY 2 01 4

F E ATU R E

flicts of interest is rooted in the lack of under-

What should be done to address conflicts

standing of professionalism. According to the

of interest?

25

bioethicists Pellegrino and Relman, the dis-

Dealing with conflicts of interests starts with

tinguishing feature of a true profession is the

declaring a doctors interests. Putting up layers

effacement of self-interest. Professionals are

of decision makers in issues where one has a

granted important privileges by society because

conflict of interest would be a good strategy as

of their social status. Doctors in particular are

well. A doctor who has conflict must inhibit him-

deemed competent, trustworthy and ethical and

self from decision-making.

are working to benefit patients and society. As a

In European healthcare systems, it has been

consequence, professionals wield the power to

shown that a shift in compensation schemes from

set educational and ethical standards.

fee-for-service to salaried system led to decrease in

Another reason is being stuck in the early

unethical practices. A simple lifestyle, open decla-

stages of moral development. Applying Kohl-

ration of personal principles and altogether avoid-

bergs Stage Theory of Moral Reasoning, physi-

ing situations that may give rise to conflicts of inter-

cians who have unethical practice are stuck at

est would help deal with the unethical practice.

the pre-conventional stage, where they respond

The American Medical Student Association

to punishment or reward. Their actions are guid-

has developed a scorecard to assess policies for

ed by personal self-interests.

conflicts of interest in American academic medi-

Some physicians are at the conventional

cal centers. Various domains, such as financial

stage where small town thinking is emphasized.

relationships with industries or industry support

The doctor is unable to see the bigger picture,

for scholarships and funds among others, are

and all his actions are guided by whats best for

evaluated. A general grading and mapping of

his family and peers without regard to the con-

institutions are then published to show the best

sequences of his actions on the larger society.

performing and the worst performing institutions.

The highest stage of moral reasoning is the


post-conventional stage, doctors embrace ethi-

A call to action

cal principles and conscientious ideas. He rec-

In summary, Tan says that the medical pro-

ognizes that he is part of a much larger society,

fession, as a community, must act to address

and he puts primary importance to the rights of

the problem of conflicts of interest as inaction

his patients as his duty.

leads to harming the integrity of the profession.

Other reasons for conflict of interest include the

Unethical practice leads to loss of esteem and

shift in the perspective of physician not as a ser-

trust, which contributes to moral decay of the

vice-oriented professional, but as an entrepreneur.

society. Conflicts of interests may harm patients

This goes hand in hand with the individualistic ap-

who receive unnecessary services, while society

proach to the practice of medicine, in contrast to

absorbs the excess burden of spending on these

seeing the medicine as a service to society.

services.

J U LY 2 01 4

M A R K E T WATC H

26

Cancer is not a death sentence, say experts

he Philippine Society of Oncology in cooperation with Parkway Cancer Centre Singa-

pore brought in cancer experts to talk on new approaches to treating cancer last May 16 and 17,
2014.
Dr. Ang Peng Tiam, medical director of Park-

way Cancer Centre, presented tumor grafting. It


involves transplanting a small biopsy of the patients cancer to an immune-deficient mouse. After the implanting, different regimens of drug are
administered to the mouse to see the tumors
reaction. This helps identify the drug combination that can possibly work on the patient.
Dr. Lim Ziyi, another senior consultant at the
center, cleared the issue of stem cell transplantation.
Although not perfected yet, he assured that
patients can benefit from it if their medical con-

Drs. Ang Peng Tiam and Lim Ziyi answering the questions
during the May 16 CME.

dition warrants it. It has been reportedly successfully used in other countries to treat autoimmune disorders and certain solid tumors.

Generika Drugstore launches MedPadala

enerika Drugstore launched the MedPadala


program to the press last May 20, 2014.

MedPadala is the first electronic gift check (EGC)


in the market that addresses the concern of OFWs
and individuals who send financial assistance to
their loved ones who need medicine allowance,

Boy Abunda, TV host, gracing the MedPadala launch.

especially medicines for maintenance or emer-

stories of OFWs. The MedPadala website (www.

gency need. With MedPadala EGC, the goal is to

medpadala.com.ph) and Generikas channel

ensure that money will be spent on medicines.

partners for MedPadala such as LBC, VMobile,

Boy Abunda, celebrity host, graced the occasion and shared with the media some real life

and Smart E-Money, Inc. were also presented in


the event.

J U LY 2 01 4

M A R K E T WATC H

27

Our Lady of Lourdes Hospital launches state-of-the-art


endoscopic ultrasound

ur Lady of Lourdes Hospitals Center for


Advanced and Therapeutic Endoscopy

launched its new Olympus EU-ME2 endoscopic


ultrasound (EUS) machine last May 12, 2014.
Drs. Evan Ong, training officer from the University of Sto. Tomas, Gastroenterology Section,
and Frederick Dy, the centers unit head, talked
about gastrointestinal endotherapy and EUS.
EUS procedures. It provides a new provision to

Leila A. Hernandez, president & CEO with Dr. Jose


Christopher Sanchez (right), medical director/VP for
medical services, and Dr. Evan Ong, the centers unit
head.

the centers existing diagnostic and therapeutic

kicked off various events, including liver endos-

services at reasonable prices.

copy workshop, lay forum on gastroesophageal

The EU-ME2 is said to bring detailed clarity to

On its second year of service and operation


since its inauguration, the center has already

reflux disease and peptic ulcer disease, and no


cash out gastroscopy for teachers.

TMC holds first postgraduate course in critical care pharmacy

he Medical City Pharmacy Department and


the Section of Critical Care Medicine held

its first postgraduate course in critical care pharmacy on April 12 to 14, 2014. A total of 157 participants the program.
The programs objectives were to provide
updated knowledge on ICU practices, protocols and guidelines; develop critical thinking

Aldrin Santiago, manager of TMC Department of Pharmacy.

in the assessment and management of ICU

The program consisted of intensive lectures

patient; identify the roles of ICU clinical phar-

on the general principles, ICU protocols, and

macists; and demonstrate the multidisciplinary

pharmacotherapeutics. Certificates of comple-

set-up of an ICU team through interactions

tion were given to all successful participants,

among clinical pharmacists, nurses, dietitians,

with corresponding Continuing Professional

doctors and other healthcare providers.

Education (CPE) units.

J U LY 2 01 4

MA R K E T WATC H

28

GNC celebrates its 20th anniversary in the Philippines

n a press conference last May 21, 2014 to


commemorate its 20th anniversary in the Phil-

ippines, General Nutrition Corporation (GNC)


announced its partnership with Alice Dixon, a
veteran actress.
Given Dixons dedication to a healthy active
lifestyle, GNC invited her to become its brand
ambassador as she is in a better position to
reach out to active career women.
Dixon revealed she uses Burn 60, a weight
loss supplement reported to increase ones energy expenditure by 60 percent. For her skin,
she regularly takes Resvitale Collagen Enhance

GNC store.

which combines French Resveratrol with BioCell

also takes Womens Ultra Mega, a time-released

Collagen. Due to her daily hectic schedule, she

vegetarian multivitamin supplement.

DOH clarifies mandatory HIV testing

ith increasing number of HIV cases in


the country, the Department of Health

(DOH) has been mulling screening for patients


suspected with HIV infection based on risk assessment. Several HIV interest groups have crit-

icized this move, citing provisions in the 1998


AIDS law that do not allow mandatory testing.
The DOH, in a statement, stressed that the
same law states that testing requires confidentiality, informed consent and counseling.
The law prohibits testing as a precondition to
employment, admission to educational institutions, exercise of freedoms of abode, entry or

persons with HIV are obliged to disclose their

stay in the country, or right to travel, or provision

status to their partners while the DOH pursues

of medical services. The law also provides that

contact tracing.

J U LY 2 01 4

N E WS

29

Doctors choose to go gently, but not


always for patients
RADHA CHITALE

efits, if regaining consciousness seemed unlikely


or if they were terminal.

ost doctors would not choose aggressive

Comparing results from the 14-question sur-

emergency measures to prolong their

vey to an identical survey 790 physicians were

own life in cases of terminal illness, according to

given in 1987 showed nearly identical views on

a recent US-based survey.

advance directives.

These views have changed little in the last

The needle has not moved very much, said

three decades, researchers found when they

lead researcher Dr. V.J. Periyakoil of the Stanford

compared the results of the 2013 survey on at-

University School of Medicine in Stanford, Cali-

titudes reflected in advanced directives to a

fornia, US.

similar survey conducted in 1987. However, just

Physician opinions differed by specialty in the

as consistently, doctors own preferences are

2013 data, with surgical specialties less in favor

not always consistent with their actions when

of advance directives while emergency physi-

faced with terminally ill patients. [PLOS ONE

cians, pediatricians and obstetricians and gy-

2014:doi:10.1371/journal.pone.0098246;JAMA

necologists were more inclined to view advance

1989; 262:24152419]

directives favorably.

For the current study, 1,081 physicians filled

Ethnicity was a factor as well, with Caucasian

out an online advance directive form as well as a

and African American doctors more in favor of

14-question survey to gauge their feelings about

advance directives compared with Latino physi-

advance directives.

cians.

An advance directive or advance health care

The influence of the culture surrounding the

directive allows an individual to specify what ac-

physician is evident in evaluations of DNR orders

tions are to be taken in the course of their medical

outside the US. In Asia, for example, immediate

care if they become incapacitated and are unable

and extended family members play a significant

to make their own decisions. One example of an

role in determining medical course of action to-

advance directive is a do not resuscitate (DNR)

gether with a physician, sometimes in lieu of the

order that specifies no cardiopulmonary resusci-

patient, even when they are lucid and able to

tation in the event of cardiac or respiratory failure.

make decisions.

The researchers reported that 88.3 percent of

One study of end-of-life care in a Singapor-

survey respondents chose DNR for themselves

ean hospital showed that 6.2 percent of patients

to not take measures that prolonged their life if

with DNR orders who were capable of discuss-

the risks of treatment outweighed expected ben-

ing them were consulted about the orders, while

J U LY 2 01 4

N E WS

30

discussions with the family occurred in 82.9 per-

what physicians would choose for themselves

cent of cases. [J Palliat Med 2011;14:1296-301]

and the volume, intensity, and cost of care the

There was a lack of commitment by doctors

average patient receives about 40 percent of

on orders for DNR/CPR and to limit life-sustaining

the national social insurance budget per patient

therapies, infrequent discussions with patients on

spent in the last 30 days of life.

end-of-life decisions, and excessive burdensome

Our current default is doing, but in any seri-

interventions with inadequate palliative care for

ous illness there comes a tipping point where the

the dying, the researchers said. These findings

high-intensity treatment becomes more of a bur-

may reflect certain Asian cultural biases.

den than the disease itself, Periyakoil said. But

In light of their findings, the researchers in the


current study noted the discrepancy between

we dont train doctors to talk or reward them for


talking the system needs to be changed.

J U LY 2 01 4

N E WS

32

Large study reaffirms sleep apnea


and diabetes link
CHUAH SU PING

Canadian study involving more than 8,500


patients with sleep apnea has demon-

strated a link between obstructive sleep apnea


(OSA) and the development of diabetes, confirming earlier evidence of such a relationship.
By following a group of patients without previous diabetes who had been referred with sus-

The study was the largest to date investigating the link


between sleep apnea and diabetes.

pected OSA over a median period of 67 months,

neck circumference and the presence of day-

researchers found that 11.7 percent (1,017 of

time sleepiness.

8,678 patients) developed diabetes, giving a cu-

Our study, with a larger sample size and lon-

mulative incidence at five years of 9.1 percent

ger period of complete follow-up, was able to ad-

(95% CI, 8.4 percent to 9.8 percent). [Am J Respir

dress some of the limitations of earlier studies on

Crit Care Med 2014. Jun 4; Epub ahead of print]

the connection between OSA and diabetes, said

Further analyses adjusting for known dia-

Kendzerska. Further, she noted, the study allowed

betes risk factors (ie, age, sex, BMI, neck cir-

assessment of many OSA-related factors beyond

cumference, smoking, income status and co-

AHI and adequate control for numerous potential

morbidities at baseline) found that patients with

confounders impossible in a smaller study. To

an apnea-hypopnea index (AHI) of more than 30

date, this is the largest study investigating the re-

had a 30 percent higher risk of developing dia-

lationship between sleep apnea and diabetes.

betes than those with an AHI less than 5.

In their paper, the authors noted: While there

We found that among patients with OSA,

have been previous studies which reported the

the initial severity of the disease and its physi-

association between OSA and incident diabetes,

ologic consequences predicted the subsequent

these studies were generally small, had few events,

risk for incident diabetes, said lead author Dr.

did not account for time-to-event in their analyses,

Tetyana Kendzerska of the University of Toronto,

and employed inconsistent definitions of OSA.

Ontario, Canada. Rapid eye movement (REM)-

They concluded that risk-stratification of pa-

AHI and time spent with oxygen saturation less

tients with OSA according to the sleep apnea-re-

than 90 percent (TiSaO2<90%) were significant

lated predictors highlighted in the study may be

predictors of incident diabetes, as were shorter

useful in identifying those most likely to develop

total sleep time, higher mean heart rate, greater

diabetes, allowing timely intervention.

J U LY 2 01 4

N E WS

33

Vibration could help people with


fibromyalgia to exercise
RADHA CHITALE

eople with fibromyalgia may find relief from

only (n=9) or an attention control group (n=8).


Participants were evaluated at baseline and at 8
weeks.

pain through full-body vibration enough to

Whole body vibration is a general term to de-

overcome their aversion to exercise, research-

note a vibration of any frequency being applied

ers say.

to the body, which forces muscles to contract

Fibromyalgic patients can enter into a nega-

and relax. In this study, participants were made

tive feedback pain cycle by avoiding exercise,

to stand, sit or lie on a vibrating platform as they

even though increased movement is a key ther-

did their exercises.

apy for fibromyalgia, which has no cure.

Pain severity improved the most among the

Over time, this can lead to additional weight

various outcome measures for the vibration

gain, as well as accompanying chronic health

group compared to both the resistance training

conditions associated with obesity, such as high

group (p=0.04) and the control group (p<0.05).

blood pressure, and type 2 diabetes, said lead

The vibration group also showed significant im-

researcher Mr. Tony Kaleth, associate professor

provement in fibromyalgia-related physical func-

in the School of Physical Education and Tourism

tion compared to the resistance training group

Management at Indiana University-Purdue Uni-

(p=0.02), though not compared with the control

versity Indianapolis in Indiana, US, during the

group (p=0.41). Changes in muscle strength

recent annual meeting of the American College

appeared unaffected between groups (p<0.05).

of Sports Medicine. [Abstract 2011-297]

Given the effects on pain, the researchers

In this pilot study, 24 adult women with fi-

suggested larger randomized trials be done to

bromyalgia were randomized to twice-weekly

examine the benefits of vibration on exercise

lower-body progressive resistance exercise with

and quality of life among patients with fibromy-

whole body vibration (n=7), resistance training

algia.

J U LY 2 01 4

N E WS

34

Combined BMI, waist-height ratio


may predict CVD, diabetes risk
ELVIRA MANZANO

ther measure. Using both BMI and WHtR together reduced the number of high-risk indi-

ody mass index (BMI) and waist-to-height

viduals to 543. Those classified as overweight

ratio (WHtR) may be a better predictor of

by either BMI or WHtR had an elevated cardio-

cardiovascular disease (CVD) and diabetes risk

metabolic profile, but one which was not sig-

than either anthropometric parameter alone, a

nificantly different from individuals with nor-

cross-sectional study in Ireland has shown.

mal weight. In contrast, subjects categorized

Not all overweight or obese patients will

as overweight or obese by both measures

develop cardiometabolic outcomes, so we are

displayed a noticeably increased risk profile,

looking for tools to identify the people who will,

with individuals in the highest tertile for both

said lead author Dr. Sean Millar, an epidemiolo-

indices being at a particularly high risk. In this

gist at University College Cork in Cork, Ireland.

group, the prevalence of high blood pressure,

Previous studies have suggested that the

insulin

resistance,

cardiometabolic-feature

WHtR is a better predictor of cardiometabolic

clustering, and prediabetes was 81 percent,

outcomes than BMI, independent of age and

55 percent, 34 percent, and 17 percent, re-

sex. [J Clin Endocrinol Metab 2010;95:1777-

spectively.

1785; Obes Rev 2012;13:275-286]. However,

Just as we would not necessarily use one

discriminatory differences between WHtR and

test alone for diagnosing a chronic condition

BMI are modest.

such as type 2 diabetes, nor do we have to

Millar and colleagues sought to determine

rely on one adiposity measurement to define

the predictive value of both BMI and WHtR for

obesity in order to detect people at high-risk

heart disease and diabetes risk factors in over-

for cardiometabolic disease, combining both

weight or obese individuals enrolled in the Cork

BMI and WHtR could provide a simple, cost-

and Kerry Diabetes and Heart Disease Study.

effective health screening tool to predict pa-

[2014 European Congress on Obesity; Abstract

tients at risk for CVD and diabetes. This could

696]

help clinicians identify individuals who should

Of 2,047 men and women included in the


study, 818 were classified as high risk by ei-

be targeted for preventive intervention, said


Millar.

SPONSORED
SYMPOSIUM
HIGHLIGHTS
SPONSORED
SYMPOSIUM
HIGHLIGHTS

Simplifyingattainment
attainmentof
oftarget
targetHbA1c:
HbA1c:
Simplifying
Fromclinical
clinicaltrial
trialto
toreal-life
real-lifepractice
practice
From
industry-sponsored
symposium
held
Sofitel
Philippine
Plaza
October
2013,
healthcare
professionals
attended
interactive
meeting
In In
anan
industry-sponsored
symposium
held
atat
Sofitel
Philippine
Plaza
onon
October
21,21,
2013,
healthcare
professionals
attended
anan
interactive
meeting
titled,
The
Milestones
A Decade
Clinical
Experience
Simplifying
Attainment
Target
A1c:
From
Clinical
Trial
Real
Life
Practice.
The
lecture
titled,
The
Milestones
ofof
A Decade
ofof
Clinical
Experience
Simplifying
Attainment
ofof
Target
A1c:
From
Clinical
Trial
toto
Real
Life
Practice.
The
lecture
was
conducted
diabetes
expert,
Augusto
Litonjua,
who
highlighted
the
significance
and
benefits
premix
insulin,
particularly
biphasic
was
conducted
byby
diabetes
expert,
DrDr
Augusto
DD
Litonjua,
who
highlighted
the
significance
and
benefits
ofof
premix
insulin,
particularly
biphasic
insulin
aspart
(BIAsp)
(NovoMix
Novo
Nordisk),
the
management
diabetes.
insulin
aspart
(BIAsp)
3030
(NovoMix
30,30,
Novo
Nordisk),
in in
the
management
ofof
diabetes.

Dr Augusto
D Litonjua
Dr Augusto
D Litonjua
EMERITUS
PROFESSOR,
COLLEGE
OF MEDICINE,
EMERITUS
PROFESSOR,
COLLEGE
OF MEDICINE,
UNIVERSITY
OF THE
PHILIPPINES,
MANILA
UNIVERSITY
OF THE
PHILIPPINES,
MANILA
PRESIDENT,
PHILIPPINE
CENTER
DIABETES
PRESIDENT,
PHILIPPINE
CENTER
FORFOR
DIABETES
EDUCATION
FOUNDATION,
EDUCATION
FOUNDATION,
INC INC

5
glycemia
mortality.
It has
been
proven
that
post-prandial Figure
Figure
3. The
1-2-3
Study:
Point
reduction
in HbA1c
with
OD,
glycemia
andand
mortality.
It 5 has
been
proven
that
post-prandial
3. The
1-2-3
Study:
Point
reduction
in HbA1c
with
OD,
plasma
glucose
(PPG)
elevation
after
lunch
predicts
cardiovascu- BIDBID
or TID
BIAsp
plasma
glucose
(PPG)
elevation
after
lunch
predicts
cardiovascuor TID
BIAsp
30123012
(CV)
better
than
other
glycemic
parameters
in type
2 dia- 10 10
lar lar
(CV)
riskrisk
better
than
other
glycemic
parameters
in type
2 diabetes
(Table
betes
(Table
1).61).6
9 9

8 8

Figure
1 Pathophysiology
of type
2 diabetes:
Figure
1 Pathophysiology
of type
2 diabetes:
1
1
Failure
of mealtime
insulin
secretion
Failure
of mealtime
insulin
secretion

8.6%
8.6%

HbA1c (%)

6 6
5

6.6%
6.6%

4 4
3

0 0

Baseline
Baseline

OD,OD,
BID,BID,
TIDTID

= once
= twice
= thrice
HbA1c
= hemoglobin
OD =OD
once
daily;daily;
BID =BID
twice
daily;daily;
TID =TID
thrice
daily;daily;
HbA1c
= hemoglobin
A1c;A1c;
BIAsp
= biphasic
insulin
aspart
BIAsp
= biphasic
insulin
aspart

*p<0.01
for comparison
between
women
and men
(post-lunch
values),
n=592
*p<0.01
for comparison
between
women
and men
(post-lunch
values),
n=592
CI = confidence
interval;
= fasting
plasma
glucose;
HbA1c
= hemoglobin
CI = confidence
interval;
FPG FPG
= fasting
plasma
glucose;
HbA1c
= hemoglobin
A1c;A1c;
= hazard
HR =HR
hazard
ratio.ratio.

In the
ASEAN
region,
overall
of BIAsp
showed
a signifiIn the
ASEAN
region,
thethe
overall
useuse
of BIAsp
30 30
showed
a significant
reduction
(-2.5)
in baseline
HbA1c
overall
incidences
reduction
(-2.5)
in baseline
HbA1c
andand
lessless
overall
incidences
In
a 2003
study
comparing
relative
contribution
both cant
a 2003
study
comparing
thethe
relative
contribution
of of
both
of hypoglycemia
after
weeks.
Patients
showed
improvements
after
24 24
weeks.
Patients
showed
improvements
FPG
PPG
levels
diurnal
hyperglycemia
showed
that
both of hypoglycemia
FPG
andand
PPG
levels
to to
diurnal
hyperglycemia
showed
that
both
in self-rated
health
scores
while
using
BIAsp
preparation.
health
scores
while
using
thethe
BIAsp
30 30
preparation.
contribute
overall
daily
glycemic
load
at all
HbA1c
levels. in self-rated
contribute
to to
thethe
overall
daily
glycemic
load
at all
HbA1c
levels.
15 15
Weight
changes
were
minimal
(Table
changes
were
alsoalso
minimal
(Table
2). 2).
They
particularly
have
approximately
equal
contribution
when Weight
They
particularly
have
approximately
equal
contribution
when
7
7
HbA1c
levels
range
from
to 9.2.
HbA1c
levels
range
from
7.37.3
to 9.2.
15 15
Table
2. Overall
NovoMix
in the
ASEAN
region
Table
2. Overall
NovoMix
30 30
useuse
in the
ASEAN
region
In terms
of management,
Nippon
ultra-rapid
Insulin
In terms
of management,
thethe
Nippon
ultra-rapid
Insulin
andand
dia-diaChange
Baseline
Efficacy
Change
in in
Baseline
Efficacy
betic
Complication
Evaluation
(NICE)
study
compared
longbetic
Complication
Evaluation
(NICE)
study
compared
thethe
longHbA
HbA
Change
in PPG
Change
in PPG
HbA
HbA
Change
in PPG
Change
in PPG
1c 1c
1c 1c
term
of insulin
aspart
human
regular
insulin,
showed
term
useuse
of insulin
aspart
andand
human
regular
insulin,
andand
showed
a lower
cumulative
incidence
of CV
events
among
insulin
aspart
a lower
cumulative
incidence
of CV
events
among
insulin
aspart
9.9%
2.5% 5.1 5.1
mmol/L 7.47.4
mmol/L
2.5%
mmol/L
mmol/L
NovoMix
30 30 9.9%
users.
Analysis
variance
in blood
glucose
parameters
such
users.
Analysis
of of
variance
in blood
glucose
parameters
such
as as NovoMix

Normal
subjects Patients
Patients
2 diabetes
Normal
subjects
withwith
typetype
2 diabetes
<8 mmol/L FPGFPG
mmol/L
FPGFPG
<8 mmol/L
12-1512-15
mmol/L
In
<12 mmol/L FPGFPG
18 mmol/L
FPGFPG
<12 mmol/L
18 mmol/L

0.800.80

Mean insulin (mm0l/L)

Mean insulin (mm0l/L)

1.001.00

7
HbA1c (%)

Table
1. Cardiovascular
in association
with
glycemic
Table
1. Cardiovascular
riskrisk
in association
with
glycemic
6 6
parameters
in type
2 diabetes
in type
2 diabetes
Insulin
kinetics
is an
important
factor
in the
management
of dia- parameters
Insulin
kinetics
is an
important
factor
in the
management
of diabetes.
Normal
insulin
secretion
is divided
three
phases.
In the Model
betes.
Normal
insulin
secretion
is divided
intointo
three
phases.
In the
tertile
vs 1st
(95%
HRHR
for for
3rd3rd
tertile
vs 1st
andand
2nd2nd
(95%
CI) CI)
Model
pathophysiology
of type
2 diabetes,
there
is insufficient
baseline
pathophysiology
of type
2 diabetes,
there
is insufficient
baseline
Men
Women
Men
Women
insulin
well
a failure
of mealtime
insulin
secretion.
This
insulin
as as
well
as as
a failure
of mealtime
insulin
secretion.
This
de-de- FPGFPG
(0.35-1.54) 2.342.34
(0.66-8.20)
0.730.73
(0.35-1.54)
(0.66-8.20)
is marked
even
with
fasting
plasma
glucose
(FPG)
levels
fectfect
is marked
even
with
fasting
plasma
glucose
(FPG)
levels
of of PPGPPG
h after
lunch)
(1.04-4.32) 5.545.54
(1.45-21.20)*
(2 h(2after
lunch)
2.122.12
(1.04-4.32)
(1.45-21.20)*
than
8 mmol/L
(Figure
lessless
than
8 mmol/L
(Figure
1).11).1
HbA1c
(0.55-2.21) 1.351.35
(0.43-4.26)
HbA1c
1.111.11
(0.55-2.21)
(0.43-4.26)

0.600.60
0.400.40
0.200.20

0.000.00
-30 -30 0 0 30 30 60 60 90 90120120150150180180210210240240
Time
(minutes)
Time
(minutes)

FPG,
PPG
HbA1c
showed
better
overall
glycemic
control
FPG,
PPG
andand
HbA1c
alsoalso
showed
better
overall
glycemic
control

= fasting
plasma
glucose
FPG FPG
= fasting
plasma
glucose

Safety
Safety

Other
Other

in the
insulin
aspart
group
within
5 years
of use
(Figure
insulin
aspart
group
within
5 years
of use
(Figure
2). 2).
physiological
insulin
profile
is composed
a basal
component in the
TheThe
physiological
insulin
profile
is composed
of aofbasal
component
Weight
Change
Weight
Change
Hypoglycemia
Hypoglycemia
meal-related
peaks.
Soluble
human
insulin
preparations
andand
meal-related
peaks.
Soluble
human
insulin
preparations
failfail
Figure
2.
Cumulative
incidences
of
primary
composite
endpoints
Figure
2.
Cumulative
incidences
of
primary
composite
endpoints
to match
normal
insulin
peaks
because
of their
slow
absorption,
to match
normal
insulin
peaks
because
of their
slow
absorption,
0.9*
0.9*
NovoMix
NovoMix
30 30
between
long-term
insulin
aspart
human
regular
long-term
useuse
of of
insulin
aspart
andand
human
regular
resulting
in postprandial
hyperglycemia.
Intermediate-acting
resulting
in postprandial
hyperglycemia.
Intermediate-acting
in- in- between
8 8
*Significant
improvement
(p<0.001)
*Significant
improvement
(p<0.001)
insulin
insulin
sulin
provides
better
basal
insulin
replacement,
even
when
sulin
provides
better
basal
insulin
replacement,
butbut
even
when
HbA1c
= hemoglobin
= postprandial
plasma
glucose
HbA1c
= hemoglobin
A1c;A1c;
PPGPPG
= postprandial
plasma
glucose
combined
with
regular
insulin,
it fails
to recreate
physiological
combined
with
regular
insulin,
it fails
to recreate
thethe
physiological
Cumulative
incidence
of primary
composite
endpoint
Cumulative
incidence
of primary
composite
endpoint
There
are
several
ongoing
trials
on
BIAsp
such
as the
SimpleThere
are
several
ongoing
trials
on
BIAsp
30,30,
such
as the
Simpleinsulin
profile.
insulin
profile.
Mix
which
aims
to compare
investigator
vs patient-driven
Mix
trialtrial
which
aims
to compare
investigator
vs patient-driven
11 11
Human
regular
insulin
(11.1%)
Human
regular
insulin
(11.1%)
titration
schemes
SimpleMix
trial),
Sit2Mix
which
titration
schemes
(ie,(ie,
SimpleMix
trial),
thethe
Sit2Mix
trialtrial
which
Insulin
aspart
(6.4%)
aspart
(6.4%)
better
manage
diabetes,
newer
preparations
mimic
To To
better
manage
diabetes,
newer
preparations
mimic
thethe
du-du- 10 10 Insulin
is investigating
effects
of adding
or substituting
BIAsp
is investigating
thethe
effects
of adding
or substituting
BIAsp
30 30
to to
9 9
al-release
insulin
concept
combining
rapid-acting
insual-release
insulin
concept
by by
combining
thethe
rapid-acting
insu8 8
sitagliptin,
EasyMix
which
is studying
efficacy
sitagliptin,
andand
thethe
EasyMix
trialtrial
which
is studying
thethe
efficacy
of of
analogues
with
basal
insulin
provide
physiologic
insulin
lin lin
analogues
with
basal
insulin
to to
provide
physiologic
insulin
7 7
BIAsp
insulin
glargine
(both
in combination
with
metBIAsp
30 30
andand
insulin
glargine
(both
OD)OD)
in combination
with
metreplacement.
This
is where
analogue
premixes
such
BIAsp
replacement.
This
is where
analogue
premixes
such
as as
BIAsp
30 30
6 6
16 16
formin
glimepiride.
formin
andand
glimepiride.
(NovoMix
used
to replace
both
meal-related
basal
(NovoMix
30)30)
cancan
be be
used
to replace
both
meal-related
andand
basal
insulin
levels.
insulin
levels.

Accumulation of CV events (%)

Accumulation of CV events (%)

5 5
4 4
3 3
2 2
1 1
0 0
0 0

Summary
Summary

Since
launch
years
ago,
BIAsp
shown
great
promSince
its its
launch
10 10
years
ago,
BIAsp
30 30
hashas
shown
great
promBIAsp
a time-tested
molecule
since
launch
in 2002,
BIAsp
30 30
is aistime-tested
molecule
since
its its
launch
in 2002,
in better
managing
type
2 diabetes
to the
wealth
of data
ise ise
in better
managing
type
2 diabetes
duedue
to the
wealth
of data
it has
since
received
approval
in the
elderly,
in children
it has
since
received
approval
forfor
useuse
in the
elderly,
in children
supported
numerous
randomized
controlled
trials
well
supported
by by
numerous
randomized
controlled
trials
as as
well
as as
years
of age,
in patients
switching
from
human
premix,
1010
years
of age,
in patients
switching
from
human
premix,
andand
1 1
2 2
3 3
4 4
5 5
real-world
clinical
experience
from
observational
studies.
It can
real-world
clinical
experience
from
observational
studies.
It can
Duration
(years)
Duration
(years)
in combination
with
anti-diabetic
drugs
(OADs).
It has
been
in combination
with
oraloral
anti-diabetic
drugs
(OADs).
It has
been
mimic
physiologic
insulin
secretion,
thus
providing
good
glycemic
mimic
physiologic
insulin
secretion,
thus
providing
good
glycemic
widely
used
in the
Europe
Asia.
Moreover,
in the
past
widely
used
in the
US,US,
Europe
andand
Asia.
Moreover,
in the
past
10 10
control
in all
parameters
monitored
FPG,
PPG
HbA1c).
in all
parameters
monitored
(ie,(ie,
FPG,
PPG
andand
HbA1c).
It It
years,
BIAsp
30 has
treated
millions
of patients
equivalent
to 10.7 There
years,
BIAsp
30 has
treated
millions
of patients
equivalent
to 10.7
There
a wealth
information
from
randomized
clinical
trials control
is aiswealth
of of
information
from
randomized
clinical
trials
is easily
titrated
a simple
intensified
dosing
regimen,
titrated
viavia
a simple
intensified
dosing
regimen,
andand
it it
2,3 2,3
million
patient-years.
million
patient-years.
that
show
significant
evidence
in favor
of BIAsp
in terms
of im- is easily
that
show
significant
evidence
in favor
of BIAsp
30 30
in terms
of imis relatively
safe
with
adverse
effects
such
hypoglycemia
safe
with
lessless
adverse
effects
such
as as
hypoglycemia
proving
HbA1c,
FPG,
PPG
rates
of hypoglycemia
with
simple is relatively
proving
HbA1c,
FPG,
PPG
andand
rates
of hypoglycemia
with
simple
weight
changes
regardless
of the
number
of injections.
These
andand
weight
changes
regardless
of the
number
of injections.
These
9,10,11
9,10,11
Dual-release
insulin
replacement
several
benefits,
which
Dual-release
insulin
replacement
hashas
several
benefits,
which
in- in- titration
titration
intensification
(N=1,121).
andand
intensification
(N=1,121).
consequently
provide
diabetic
patients
with
overall
good
willwill
consequently
provide
diabetic
patients
with
an an
overall
good
clude
mimicking
physiological
insulin
release
while
reducing
clude
mimicking
physiological
insulin
release
while
reducing
hy-hysense
of health
in turn,
help
prevent
mortality
morbidity
of health
andand
in turn,
help
prevent
mortality
andand
morbidity
poglycemic
compared
to conventional
premix.
It also
provides Aside
poglycemic
riskrisk
compared
to conventional
premix.
It also
provides
Aside
from
this,
real-world
clinical
experiences
based
from
this,
real-world
clinical
experiences
based
on on
ob-ob- sense
related
to poor
glycemic
control.
Further
studies
underway
to poor
glycemic
control.
Further
studies
areare
underway
to to
simplified
twice-daily
dosing
that
provide
satisfactory
glyce- servational
simplified
twice-daily
dosing
that
cancan
provide
satisfactory
glyceservational
studies
from
patients
coming
from
a wide
variety
studies
from
patients
coming
from
a wide
variety
of of related
help
better
maximize
potential
of this
preparation
in diabetes
better
maximize
thethe
potential
of this
preparation
in diabetes
control.
NovoMix
a biphasic
insulin,
which
a mixture therapies
micmic
control.
NovoMix
30 30
is aisbiphasic
insulin,
which
is aismixture
therapies
prove
that
there
is significant
improvement
alsoalso
prove
that
there
is significant
improvement
in in help
management.
of long-acting
insulin
aspart
(70%)
rapid-acting
insulin
aspart HbA1c
of long-acting
insulin
aspart
(70%)
andand
rapid-acting
insulin
aspart
HbA1c
levels
with
of BIAsp
that
there
is high
as high
levels
with
thethe
useuse
of BIAsp
30,30,
andand
that
there
is as
as as management.
References:
(30%).
This
combination
targets
both
fasting
mealtime
(30%).
This
combination
targets
both
fasting
andand
mealtime
glu-glu- a 2%
a 2%
- point
reduction
from
baseline
8.6%
to 6.6%)
with
once References:
- point
reduction
from
baseline
(ie,(ie,
8.6%
to 6.6%)
with
once
1. Coates
al. Diabetes
ResPract
Clin Pract
1994;26:177-87.
Health;
MIDAS,
March
3. NovoMix
1. Coates
PA, etPA,
al. et
Diabetes
Res Clin
1994;26:177-87.
2.IMS2.IMS
Health;
MIDAS,
March
2002 2002
April April
2011.2011.
3. NovoMix
4 4
30 Summary
of Product
Characteristics
4.NovoMix
30 Approved
Product
Information.
DECODE
of Product
Characteristics
(EU).(EU).
4.NovoMix
30 Approved
Product
Information.
5.The5.The
DECODE
StudyStudy
cose
at the
same
time.
cose
at the
same
time.
(OD),
twice
(BID)
or thrice
(TID)
daily
dosing
with
prepara- 30 Summary
(OD),
twice
(BID)
or thrice
(TID)
daily
dosing
with
thethe
saidsaid
preparaGroup.
Lancet
1999;354:617-21.
6. Cavalot
F, et
al. JEndocrin
Clin Endocrin
2006;91:813-9.
7. Monnier
L, et
al. Diabetes
Group.
Lancet
1999;354:617-21.
6. Cavalot
F, et al.
J Clin
MetabMetab
2006;91:813-9.
7. Monnier
L, et al.
Diabetes
Care Care
2003;26:881-5.
8. Nishimura
al. Diabetes
2008;57(Suppl
1):163-OR.
9. Raskin
P, et
al. Diabetes
Care 2005;28:2608. Nishimura
H, et H,
al. et
Diabetes
2008;57(Suppl
1):163-OR.
9. Raskin
P, et al.
Diabetes
Care 2005;28:260(Figure
Stepwise
regression
showed
that
there
tiontion
(Figure
3). 3).
Stepwise
regression
alsoalso
showed
that
there
waswas 2003;26:881-5.
10. Kann
PH,
al.Clin
ExpEndo
Clin Endo
2006;114:527-32.
11. Strojek
al. Med
Curr Res
MedOpin
Res Opin
2009;25:2887-944.
5. 10.5.Kann
PH, et
al.et
Exp
Diab Diab
2006;114:527-32.
11. Strojek
K, et K,
al.et
Curr
2009;25:2887-944.
With
regard
better
glycemic
control
diabetes
outcomes, no no
With
regard
to to
better
glycemic
control
andand
diabetes
outcomes,
correlation
with
hypoglycemia
between
phases/number 12. Garber
correlation
with
hypoglycemia
between
thethe
phases/number
12. Garber
al. Diabetes
2006;8:58-66.
13. Valensi
P, et
Int JPract
Clin Pract
2009;63:522-31.
14. Home
AJ, etAJ,
al. et
Diabetes
Obes Obes
MetabMetab
2006;8:58-66.
13. Valensi
P, et al.
Intal.
J Clin
2009;63:522-31.
14. Home
P, P,
al. Diabetes
ResPract
Clin Pract
2011;94:352-63.
15. Lim-Abrahan
MA,
al. Diabetes
ResPract
Clin Pract
2013;100(Suppl
1):S3-S9.
et al. et
Diabetes
Res Clin
2011;94:352-63.
15. Lim-Abrahan
MA, et
al. et
Diabetes
Res Clin
2013;100(Suppl
1):S3-S9.
12,13,14
12,13,14
studies
show
a significant
association
between
post-challenge of injections.
studies
show
a significant
association
between
post-challenge
of injections.
16. Liebl
al. Drugs
2012;30:72:1495-520.
16. Liebl
A, et A,
al. et
Drugs
2012;30:72:1495-520.

Novo
Nordisk
Pharmaceuticals
Novo
Nordisk
Pharmaceuticals
(Philippines)
(Philippines)
Inc. Inc.
Unit 2006,
20/FSan
OneMiguel
San Miguel
Ave. Bldg.,
San Miguel
Ave. cor.
Unit 2006,
20/F One
Ave. Bldg.,
San Miguel
Ave. cor.
Ortigas
Center,
City, Philippines
ShawShaw
Blvd.,Blvd.,
Ortigas
Center,
1605,1605,
PasigPasig
City, Philippines
Contact
Number:
667 3661
Contact
Number:
+632 +632
667 3661
Website:
www.novonordisk.com
Website:
www.novonordisk.com

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J U LY 2 01 4

CO N F E R E N C E COV E R AG E

36

2014 American Society of Clinical Oncology (ASCO) Annual Meeting,


30 May 3 June, Chicago, US

Aromatase inhibition works in


premenopausal women with
early breast cancer
CHRISTINA LAU

and followed for a median of 5.7 years.


Exemestane plus OFS significantly im-

djuvant exemestane outperforms tamoxifen

proved the primary endpoint of disease-free

in premenopausal women with hormone

survival [DFS], reported Dr. Olivia Pagani of the

receptor (HR)-positive early breast cancer, but

Oncology Institute of Southern Switerzerland,

dual HER2 blockade with lapatinib plus trastu-

Bellinzona, Switzerland.

zumab works no better than trastuzumab alone

At 5 years, the DFS rate was 91.1 percent for

in women with HER2-positive early breast can-

exemestane vs 87.3 percent for tamoxifen (haz-

cer after surgery.

ard ratio [HR], 0.72). Furthermore, significantly

In premenopausal patients with HR-positive

more patients treated with exemestane were

early breast cancer, current standard adjuvant

free from breast cancer (92.8 vs 88.8 percent for

treatment is tamoxifen for at least 5 years. Aro-

tamoxifen; HR, 0.66) or distant recurrence (93.8

matase inhibitors (AIs) are used primarily in

vs 92 percent; HR, 0.78) at 5 years.

postmenopausal women because their use requires low estrogen levels.

The adverse event profile of exemestane


plus OFS mirrored that of exemestane seen in

A joint analysis of the phase III Tamoxifen and

postmenopausal women, said Pagani. This

Exemestane Trial (TEXT) and the Suppression of

combination therefore offers a new treatment

Ovarian Function Trial (SOFT), however, showed

option for premenopausal women with HR-posi-

that the AI exemestane reduced the relative risks

tive early breast cancer.

of breast cancer recurrence by 34 percent and

In women with HER2-positive early breast

subsequent invasive cancer by 28 percent vs

cancer, trastuzumab will likely remain the stan-

tamoxifen when used concurrently with ovarian

dard adjuvant treatment as concurrent or se-

function suppression (OFS) in premenopausal

quential use of lapatinib demonstrated no ben-

patients. [Abstract LBA1]

efit in the phase III ALTTO (Adjuvant Lapatinib

In the trials, 4,690 patients (average age, 43


years) were randomized to 5 years of adjuvant
exemestane or tamoxifen, both given with OFS,

and/or Trastuzumab Treatment Optimization)


trial of 8,381 patients. [Abstract LBA4]
The trial did not meet its primary endpoint of

J U LY 2 01 4

CO N F E R E N C E COV E R AG E

37

DFS, reported Dr. Martine Piccart-Gebhart of the

into improved survival outcomes in ALTTO after

Breast International Group. The 4-year DFS rate

a median follow-up of 4.5 years, she continued.

was 88 percent for concurrent lapatinib and trastu-

Anti-HER2 combination therapy was, how-

zumab, 87 percent for trastuzumab followed by

ever, associated with significantly higher rates

lapatinib, and 86 percent for lapatinib alone.

of diarrhea (50-75 vs 20 percent), hepatobiliary

The doubling of pathological complete re-

toxicity (23-24 vs 16 percent), and skin rash or

sponse observed with lapatinib plus trastuzumab

erythema (49-55 vs 20 percent) vs trastuzumab

in the previous NeoALTTO trial did not translate

alone.

Come join the leading minds at


10th Asia Pacific Congress in

Maternal Fetal Medicine


Fri 22 Sun 24 August 2014

Suntec Singapore Convention and Exhibition Centre, Singapore


Obstetrical & Gynaecological
Society of Singapore

Keynote Speakers:

STAN: Is It the Future


of Intrapartum
Monitoring?

Fetal Therapy
for Complicated
MC Twins

Prof Sir Sabaratnam


ARULKUMARAN (UK)

Prof Yves VILLE (France)

Prof Dennis LO

Necker-Enfants-Malades
Hospital, Paris Descartes
University

(Hong Kong)

President, International
Society of Ultrasound in
Obstetrics and Gynaecology
(ISUOG)

The Chinese University of


Hong Kong (CUHK)

St Georges University of
London
President, International
Federations of Obstetrics
and Gynaecology (FIGO)

Non-Invasive
Prenatal DNA Testing:
Now & Future

Li Ka Shing Institute of
Health Sciences

Faculty:
Biswas ARJIT (Singapore)

Devendra KANAGALINGAM (Singapore)

Leona POON (UK)

TP BASKARAN (Malaysia)

LAO Tzu Hsi Terence (Hong Kong)

Daljit Singh SAHOTA (Hong Kong)

BUI The-Hung (Sweden)

LAW Lai Wa (Hong Kong)

Walfrido SUMPAICO (Philippines)

CHANG Tou Choong (Singapore)

LEE Keun-Young (Korea)

SUN Luming (China)

CHENG KY Yvonne (Hong Kong)

LEE Mi-Young (Korea)

TAN Eng Kien (Singapore)

CHOY KW Richard (Hong Kong)

LEUNG Tak Yeung (Hong Kong)

TAN Lay Kok (Singapore)

Gustaaf DEKKER (Australia)

Choolani MAHESH (Singapore)

Tony TAN (Singapore)

Tim DRAYCOTT (UK)

Endoh MASAYUKI (Japan)

TAN Wei Ching (Singapore)

HUI Shuk Yi Annie (Hong Kong)

Ritu MOGRA (Australia)

WATAGANA Tuangsit (Thailand)


Hye-Sung WON (Korea)

Jonathan HYETT (Australia)

Dear Colleague,
The Asia Pacific Congress in Maternal Fetal Medicine (APCMFM), established by the Fetal Medicine Foundation, United
Kingdom (www.fetalmedicine.com) and The Chinese Fetal Medicine Foundation, Hong Kong (www.fetalmedicine.hk),
convenes specialists doctors, trainees, nurses and allied health workers involved in the clinical and scientific aspects of
prenatal diagnosis, obstetrics, gynaecology, ultrasonography and genetics, in the field of maternal fetal medicine.
As the 10th APCMFM 2014 comes to be hosted in Singapore by the Obstetrical & Gynaecological Society, Singapore
in a fast-rising hub which healthcare resources and expert collaborations are engaging regional neighbours interests
we encourage you and your colleagues to come join the worlds leading minds in maternal fetal medicine today.
We warmly look forward to welcoming you here in Singapore at this 10th Anniversary occasion on 22-24 August 2014,
and be part of the conversations in maternal fetal medicine today.
Yours Sincerely,

Prof. LEUNG Tak Yeung

Dr. Tony TAN

Co-chairman
Hong Kong

Co-chairman
Singapore

For registration, programme, full speakers line-up and updates

PLEASE VISIT WWW.APCMFM.HK TODAY

For registration, programme, full speakers line-up and updates

PLEASE VISIT WWW.APCMFM.HK TODAY


CALL-FOR-ABSTRACTS OPEN UNTIL 22 MAY 2014

ENJOY THE EARLY BIRD RATE UNTIL 22 JUNE 2014

Submit your original work for poster presentation consideration


at the APCMFM website soonest.

Be a part of this congress that gathers the best of maternal


fetal medicine in the Asia Pacific region.

10th APCMFM PROGRAMME HIGHLIGHTS


Day 1: Fri 22 Aug 2014

Day 2: Sat 23 Aug 2014

Day 3: Sun 24 Aug 2014

Session 2.1
Ferring's Symposium 1: Born Too Early

Session 3.1
High Risk Labour

Chairpersons: LEUNG Tak Yeung (Hong Kong) & Tony TAN (Singapore)

Chairpersons: TBC

Prediction of Preterm Delivery and Prophylactic Progesterone

Medico-Legal Issue in Shoulder Dystocia

Speaker: Leona POON (UK)

Speaker: LAO Tzu Hsi Terence (Hong Kong)

STAN: Experience in Singapore

Cervical Pessary for Prevention of Preterm Delivery

Whats New in VBAC?

Speaker: Biswas ARJIT (Singapore)

Speaker: HUI Shuk Yi Annie (Hong Kong)

Speaker: TAN Eng Kien (Singapore)

Urgent Caesarean Section for Fetal Distress

Surgical Cerclage for Prevention of Preterm Delivery

Obstetrical DIC

Speaker: LEUNG Tak Yeung (Hong Kong)

Speaker: LEE Keun-Young (Korea)

Speaker: Gustaaf DEKKER (Australia)

Identifying Distressed and 'Near-Miss' Neonates


at Birth

Acute Tocolysis for Preterm Labour

Active Management of Labour - A Thing of the Past?

Speaker: LEUNG Tak Yeung (Hong Kong)

Speaker: Devendra KANAGALINGAM (Singapore)

Session 1.2
Pre-Eclampsia: Prevention, Monitoring & Treatment

Session 2.2
Ferrings Symposium 2: Born Too Late

Session 3.2
Update in Antenatal Screening & Monitoring

Chairpersons: LAO Tzu Hsi Terence (Hong Kong) &


TAN Lay Kok (Singapore)

Chairpersons: Sabaratnam ARULKUMARAN (UK) & TBC

Chairpersons: D CHAROENVIDHYA & TBC

Biophysical and Biochemical Markers for Preeclampsia

Induction of Labour - When to Wait & When to Induce?

NIPT vs USG & Biochemical Screening for Aneuploidies

Speaker: Leona POON (UK)

Speaker: Tony TAN (Singapore)

Speaker: Jonathan HYETT (Australia)

Calculation of Pre-Eclampsia Risk

Pharmacological Induction of Labour

Maternal Fragile X Carrier Screening

Speaker: Daljit Singh SAHOTA (Hong Kong)

Speaker: Tim DRAYCOTT (UK)

Speaker: CHENG KY Yvonne (Hong Kong)

1st Trimester Screening: From Research to Clinical


Practice

Mechanical Induction of Labour

Screening & Monitoring of Early Onset IUGR

Speaker: LAO Tzu Hsi Terence (Hong Kong)

Speaker: CHANG Tou Choong (Singapore)

2nd Trimester Surveillance of Pre-Eclampsia

Prevention of PPH Following Induction of Labour

Screening & Monitoring of Late Onset IUGR

Speaker: WATAGANA Tuangsit (Thailand)

Speaker: Tim DRAYCOTT (UK)

Speaker: TAN Wei Ching (Singapore)

Session 1.3
USG Meets Genetics

Session 2.3
Maternal Medicine: What Are Overlooked?

Reversed Pyramid Model: Does It Really Work?

Chairpersons: Hye-Sung WON (Korea) & TBC

Chairpersons: Gustaaf DEKKER (Australia) & TAN Lay Kok (Singapore)

Ambiguous Genitalia & Genetic / Genomic Syndromes

Maternal-Fetal Hepatitis: Just Infection?

Speaker: LEUNG Tak Yeung (Hong Kong)

Speaker: LAO Tzu Hsi Terence (Hong Kong)

Cardiac Malformations & Genetic / Genomic


Syndromes

Maternal-Fetal Hepatitis: Just Infection?

KEYNOTE: NON-INVASIVE PRENATAL DNA TESTING: NOW & FUTURE

Speaker: LAO Tzu Hsi Terence (Hong Kong)

Speaker: Dennis LO (Hong Kong)

Facial Malformations & Genetic / Genomic Syndromes

Acquired and Inherited Thrombophilias Revisit

Variation in the Laboratory Methodology in NIDT

Speaker: TBC

Speaker: TAN Lay Kok (Singapore)

Speaker: WATAGANA Tuangsit (Thailand)

Session 1.1
Advances in Intrapartum Monitoring & Management
of Birth Asphyxia
Chairpersons: LEUNG Tak Yeung (Hong Kong) &
Tony TAN (Singapore)

KEYNOTE: STAN: IS IT THE FUTURE OF INTRAPARTUM


MONITORING
Speaker: Sabaratnam ARULKUMARAN (UK)

Speaker: Jonathan HYETT (Australia)

Speaker: Jonathan HYETT (Australia)

Speaker: Leona POON (UK)

Session 3.3
Non-Invasive Prenatal Dna Testing (NIDT)
Chairpersons: LEUNG Tak Yeung (Hong Kong) & BUI The-Hung (Sweden)

Speaker: LEE Mi-Young (Korea)

IUGR and Macrosomia & Genetic / Genomic Syndromes Acquired and Inherited Thrombophilias Revisit

What Causes the False Positive and False Negative in NIPT?

Speaker: Yves VILLE (France)

Speaker: TAN Lay Kok (Singapore)

Speaker: CHOY KW Richard (Hong Kong)

Investigation of Genomic Disorders: ACGH or


Next Generation Sequencing?

Beware of Maternal Malignancies

Debate: Amniocentesis Should Be Offered to All Obstetric Patients

Speaker: LAW Lai Wa (Hong Kong)

Proposition & Opposition: TBC

Iron Deficiency Anaemia and Management in Pregnancy

Session 3.4
Asia & Oceania Federation of Obstetrics & Gynaecology (AOFOG)
Session: Challenging the Conventional Practices

Speaker: BUI The-Hung (Sweden)

Session 1.4
How Good Is 1st Trimester Fetal Ultrasound?

Speaker: Gustaaf DEKKER (Australia)

Chairpersons: Jonathan HYETT (Australia) & TBC

Chairpersons: TBC

Fetal Chest Assessment & Malformations in 1st


Trimester

Session 2.4
Development of Fetal Therapy in Asia

Speaker: Hye-Sung WON (Korea)

Chairpersons: LEUNG Tak Yeung (Hong Kong) & Jonathan HYETT (Australia)

Fetal Brain Assessment & Malformations in 1st


Trimester

KEYNOTE: FETAL THERAPY FOR COMPLICATED MC TWINS

Unconventional Ways to Prolong Gestation in Multiple Pregnancies

Speaker: Yves VILLE (France)

Speaker: Tony TAN (Singapore)

Interventions for Fetal Lung Malformations & Pleural Effusion

Challenges to Evidence Based Care in Obstetrics

Speaker: Endoh MASAYUKI (Japan)

Speaker: Sabaratnam ARULKUMARAN (UK)

1st Trimester Fetal Morphological Assessment


Experience in India

Fetal Diaphragmatic Hernia: Fetoscopic Balloon Occlusion of


Trachea

Unconventional Ways to Prolong Gestation in Multiple Pregnancies

Speaker: S SURESH

Speaker: LEUNG Tak Yeung (Hong Kong)

Challenges to Evidence Based Care in Obstetrics


Speaker: Sabaratnam ARULKUMARAN (UK)

Speaker: Ritu MOGRA (Australia)

Fetal Abdominal Assessment & Malformations in 1st


Trimester
Speaker: TP BASKARAN (Malaysia)

Speaker: Tony TAN (Singapore)

Development of Fetal Therapy in China

Are Current Labor Curves or Partograms No Longer Relevant?

Speaker: SUN Luming (China)

Speaker: Walfrido SUMPAICO (Philippines)

Aortic Stenosis and Balloon Dilatation?


Speaker: TBC

Interventions for Fetal Bladder Outflow Obstruction


Speaker: Hye-Sung WON (Korea)

Telementoring and the Learning Curve for Fetoscopic Surgery


Speaker: S SURESH

Fetal Stem Cell Therapy


Speaker: Choolani MAHESH (Singapore)

Advanced Fetal Care in Asia: Critical Looking to the Future


Speaker: WATAGANA Tuangsit (Thailand)

J U LY 2 01 4

CO N F E R E N C E COV E R AG E

40

2014 American Society of Clinical Oncology (ASCO) Annual Meeting,


30 May 3 June, Chicago, US

Docetaxel should join first-line ADT


for metastatic prostate cancer
JACKEY SUEN

and followed up for a median of 29 months.


Fewer prostate cancer-related deaths were

dding docetaxel to first-line androgen de-

reported in the ADT plus docetaxel arm (n=84)

privation therapy (ADT) benefits patients

than in the ADT-alone arm (n=112). The median

with metastatic prostate cancer and justifies the

OS was improved by more than 13 months with

extra treatment burden, a study suggests. [Ab-

docetaxel (57.6 vs 44.0 months; hazard ratio

stract LBA2]

[HR], 0.61; p=0.0003).

ADT has been a standard first-line treatment

The benefit of adding docetaxel to ADT was

for hormone-sensitive prostate cancer since the

more pronounced in patients with high-extent

1950s. Most patients with hormone-sensitive

metastatic disease, showing a 17-month increase

prostate cancer treated with ADT eventually

in median OS vs ADT alone [49.2 vs 32.2 months;

become resistant to the therapy, requiring sub-

HR, 0.60; p=0.0006], reported Sweeney.

sequent chemotherapy, such as docetaxel, to


improve survival.

At 1 year, ADT plus docetaxel almost doubled


the percentage of patients with prostate-specif-

In the CHAARTED study [Chemohormonal

ic antigen <0.2 ng/mL (22.7 percent vs 11.7

Therapy Versus Androgen Ablation Random-

percent for ADT alone). The median times to

ized Trial for Extensive Disease in Prostate Can-

castration-resistant prostate cancer and clinical

cer], we hypothesized that adding docetaxel

progression were also prolonged with docetaxel

at the time of ADT initiation for hormone-nave

plus ADT [HR, 0.56 and 0.49, respectively].

metastatic prostate cancer patients will prolong

The safety profile of ADT plus docetaxel was

overall survival [OS], said lead investigator

acceptable, with 90 percent of patients complet-

Dr. Christopher Sweeney of the Lank Center

ing all six cycles of ADT plus docetaxel and 74

of Genitourinary Oncology at the Dana-Farber

percent requiring no dose modifications. About

Cancer Institute, Boston, Massachusetts, US.

a quarter of patients experienced grade 3 or 4

Patients are also relatively fit for docetaxel at

hematologic toxicity.

an early stage of treatment.

The benefits of docetaxel plus ADT in pros-

In the CHAARTED study, 790 men with meta-

tate cancer patients with a high volume of me-

static prostate cancer were randomized to re-

tastasis are clear and justify the treatment bur-

ceive ADT alone or with six cycles of docetaxel,

den, he concluded.

J U LY 2 01 4

CO N F E R E N C E COV E R AG E

41

2014 American Society of Clinical Oncology (ASCO) Annual Meeting,


30 May 3 June, Chicago, US

Turning mCRC into a chronic disease


CHRISTINA LAU

preference (FOLFIRI, 26.6 percent; FOLFOX,


73.4 percent). The primary endpoint was OS.

etastatic colorectal cancer (mCRC) is be-

Results showed no difference between the

coming a chronic disease as a robust,

bevacizumab and cetuximab arms in OS (medi-

publicly-funded study showed that patients can

an, 29 vs 29.9 months; hazard ratio [HR], 0.925;

survive for almost 30 months with bevacizumab

p=0.34) and progression-free survival (median,

or cetuximab in combination with standard first-

10.8 vs 10.4 months; HR, 1.04; p=0.55). OS

line chemotherapy regimens.

was similar between the targeted agents when

These results, from the phase III CALGB/


SWOG 80405 trial, showed no difference in

outcomes were analyzed according to chemotherapy backbone.

overall survival (OS) with either biologic therapy

Patients who became disease-free after sur-

in a subset of patients with no mutation in co-

gery did exceedingly well, pointed out Venook.

dons 12 and 13 of the KRAS gene.

In these patients, who accounted for 10.9 per-

Patients with KRAS wild-type mCRC can


now have choices, said Professor Alan Venook

cent of the study population, median OS exceeded 5.5 years.

of the University of California in San Francisco,

In the study, 29.6 percent of patients (27.2

California, US, who presented the results. [Ab-

percent for bevacizumab, 31.8 percent for cetux-

stract LBA3]

imab) discontinued treatment due to progressive

Bevacizumab and cetuximab can both be


considered as first-line treatment options in

disease. Eighty-eight percent of study patients


received further lines of therapy, said Venook.

combination with a chemotherapy backbone

Median survival of patients in CALGB/

of FOLFIRI [leucovorin, 5-FU, irinotecan] or

SWOG 80405 is approximately 7 months longer

FOLFOX [leucovorin, 5-FU, oxaliplatin], he

than their counterparts in previous large-scale

suggested. The choice of first-line therapy

studies, noted discussant Dr. Joseph Taber-

should reflect the patients preference or con-

nera of the Vall dHebron University Hospital

cern about potential side effects.

and Institute of Oncology in Barcelona, Spain.

In the CALGB/SWOG 80405 trial, 1,137 pa-

While CALGB/SWOG 80405 showed that ce-

tients with KRAS wild-type mCRC were random-

tuximab is not superior to bevacizumab in first-

ized to receive bevacizumab or cetuximab in

line treatment of KRAS wild-type mCRC, this

combination with FOLFIRI or FOLFOX. Selec-

may change when results of expanded RAS

tion of chemotherapy was based on physician

mutation analysis becomes available.

J U LY 2 01 4

I N P R AC TI C E

42

PE in Asia
Dr. Angela Ng
Family Physician and Sex Therapist
Ng Wing Ying Angela Clinic,
Hong Kong

do not actively seek to address them, unless


they are functionally impacted or require hospital admission.
In many Asian societies even the more metropolitan societies that profess to have an open

culture issues like sexual dysfunctions remain

remature ejaculation (PE) is the most com-

a taboo and are not openly discussed. These

mon sexual dysfunction affecting men and

social norms further impede the diagnosis of

yet not many in Asia have sought treatment or

PE and its treatment, and can result in under-

will even admit to having a problem. PE occurs

diagnosis.

when a man experiences orgasm and expels semen too quickly after sexual activity with minimal penile stimulation. [J Urol 2008; 179(suppl),
340, abstract 988]

Misconceptions of PE
The general reluctance of individuals to speak
about PE together with the lack of awareness of

A recent comprehensive study of 5,000 men

PE as a medical condition means that many are

across nine countries, The Asia-Pacific Prema-

also not aware that it is a treatable condition. Ad-

ture Ejaculation Prevalence and Attitude Study

ditionally, PE is often misdiagnosed as erectile

(PEPA), found that 31 percent of men have PE.

dysfunction (ED) and therefore patients fail to

[J Sex Med 2012;9:454-465] Yet the concern is

receive effective medication for their condition.

only a small proportion (7 percent) have been

It is important to note that while ED tends to af-

diagnosed and treated with this condition. [Asia-

fect older men, PE affects men across all age

Pacific Sexual Behaviors and Satisfaction Sur-

groups.

vey, May 2013]

PE can be classified as either lifelong or ac-

The PEPA study also identified a significant

quired PE. While there are no concrete medi-

gap between those who actually had PE and

cal studies that validate this, it is believed that

those who perceived themselves to have the

there are genetic factors behind lifelong PE.

condition. About two-thirds of the respondents

More specifically, neurobiological factors such

who were diagnosed with PE via the Premature

as the levels of serotonin in an individual can

Ejaculation Diagnostic Tool (PEDT), interesting-

contribute and affect the development of PE in

ly, did not self-report having the condition.

an individual which can be tied to genetic pre-

This perception gap is a critical barrier when

disposition.

it comes to seeking treatment for PE, which can

Acquired PE on the other hand has both

be treated with appropriate medical help. Typi-

physiological and psychological roots. For indi-

cally, when it comes to health issues, most men

viduals with acquired PE, they have previously

J U LY 2 01 4

I N P R AC TI C E

43

experienced periods of normal sexual activity

makes it more difficult for them to attain orgasm

before developing PE symptoms. In terms of

and this may result in a high level of stress and

physiology, organic diseases of the prostrate

anxiety.

and/or thyroid can all lead to acquired PE. Psy-

In the long run, PE puts a severe strain in the

chological factors such as prolonged stress

development of a healthy, loving and sexually

may also play a part.

fulfilled relationship between two individuals.


In fact 40 percent of partners of men with PE

Burden of PE

say that it causes them to avoid sex completely

The reason why physicians should be placing

and 14 percent of women in Asia say that they

urgency on the early diagnosis and treatment of

believe that PE could lead to actual relationship

PE is its burden on sufferers and their partners.

breakdown or divorce. [Asia-Pacific Sexual Be-

PE will negatively affect sexual satisfaction and

haviors and Satisfaction Survey, May 2013]

intimacy, which can eventually translate to problems in the relationship. Reports have indicated

The role of women

that only 38 percent of partners of men with

Women play an important role in helping

PE are sexually satisfied, compared to 90 per-

their partners with suspected PE get diagnosed.

cent of partners of men without PE. [J Sex Med

However, Asian women are especially hesitant

2005;2:358-367]

to talk about sex; they are unwilling to broach

Aside from sexual satisfaction, PE also can

such conversations for fear of embarrassing

impact the level of self-confidence and self-es-

themselves or their partners. Often in Asia, an

teem of a man and equally so his partner.

appreciation of a healthy sex life or the desire

Within a relationship between a PE sufferer

to improve frequency of sex is seen as being

and his partner, both parties commonly report

linked to promiscuity, which is an undesirable

feelings of alienation and lowered self-confi-

and stigmatized trait in women in conservative

dence. Men in particular feel embarrassed when

societies.

they fail to sexually satisfy their partner. Pro-

We also see busy, hectic lifestyles, work, fam-

longed stress and irritation from the lack of sex-

ily and other commitments being prioritized over

ual satisfaction attributed to PE can negatively

sexual fulfillment in relationships. That, along

impact the ability of an individual to maintain or

with a common misconception that sexual ful-

engage in interpersonal relationships.

fillment is not or should not be a priority are


some social factors that impede the successful

The impact on women

diagnosis and treatment of PE.

Often, partners of men with PE are overlooked as the heavy impact it has on them is

PE is a treatable condition

not realized let alone acknowledged. In general,

Looking at PE in Asia, much still needs to

women need a longer time to reach orgasm. PE

be done to raise awareness of PE as a medical

J U LY 2 01 4

I N P R AC TI C E

44

condition. Within the medical community alone,

how to diagnose PE, and the differences be-

initiating conversations about the importance of

tween PE and other sexual dysfunctions would

sexual satisfaction and sexual health are criti-

help us be able to better advise and treat our

cal steps towards the effective diagnosis of PE.

patients. Medical improvements and newly ap-

Physicians and therapists play an important role

proved drugs such as dapoxetine mean that

in dispelling stigma and misconceptions about

men no longer have to suffer in silence and can

PE. Equipping ourselves with the information

regain their quality of life both for themselves

on how to openly and effectively talk about sex,

and their partners.

About the author


Dr. Angela Ng is a family physician and sex therapist. She has contributed extensively to the
discussion of issues concerning sexual health and is an opponent of sexual abuse.

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J U LY
19th WONCA Europe Conference
2/7/2014 to 5/7/2014
Location: Lisbon, Portugal
Info: Secretariat
Tel: (351) 217 712 634
Fax: (351) 217 712 639
Email: registration.wonca2014@
leading.pt
Website: http://woncaeurope2014.org
23rd Biennial Congress of the
European Association for Cancer
Research (EACR-23)
5/7/2014 to 8/7/2014
Location: Munich, Germany
Info: European CanCer Organisation
(ECCO)
Tel: (32) 2 775 02 01
Fax: (32) 2 775 02 00
Email: eacr23@ecco-org.eu
Website: www.ecco-org.eu/EACR23
20th International AIDS Conference
(AIDS 2014)
20/7/2014 to 25/7/2014
Location: Melbourne, Australia
Info: AIDS 2014 Secretariat
Tel: (41) 22 710 0800
Email: info@aids2014.org
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AUGUST
10th Asia Pacific Congress in
Maternal Fetal Medicine
22/8/2014 to 24/8/2014
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Tel: (852) 2632 1535
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Hospital Management Asia 2014
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hospitalmanagementasia.com

J U LY 2 01 4

European Society of Cardiology


Annual Congress
30/8/2014 to 3/9/2014
Location: Barcelona, Spain
Info: ESC Customer Service
Tel: (33) 492 94 7600
Fax: (33) 492 94 7601
Email: congress@escardio.org
Website: www.escardio.org/
congresses/esc-2014
UPCOMING
8th International Liver Cancer
Association Annual Conference
5/9/2014 to 7/9/2014
Location: Kyoto, Japan
Info: ILCA
Tel: (32) 2 789 2345
Fax: (32) 2 743 1550
Email: info@ilca-online.org
Website: www.ilca2014.org
54th Interscience Conference
on Antimicrobial Agents &
Chemotherapy
5/9/2014 to 9/9/2014
Location: Washington, D.C., US
Info: American Society of Microbiology
Tel: (1) 202 737 3600
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European Respiratory Society
(ERS) International Congress
6/9/2014 to 10/9/2014
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Asia Pacific Stroke Conference 2014
12/9/2014 to 14/9/2014
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C A L E N DA R

46

Trans Catheter Therapeutics (TCT)


2014
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50th European Association for the
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15/9/2014 to 19/9/2014
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J U LY 2 01 4

H U MO R

48

I just want to make it clear that theres a limit to


what homeopathy can do!

You guys didnt forget about the remodeling starting


today, did you?

We think youre taking this


casual Friday thing a little too far!

I dont get it doctor ... lately, I feel a sense


of hopelessness, like there is no future. Im drifting
in a sea of despair and nobody gives a damn!

Dr. Dongfang has a great


understanding with his patients.
They dont try to understand
him and he doesnt try to
understand them!

I take it you believe in God?

It kinda looks like a spider.


No wait ... I would say more
like a tarantula!

4th coNGress oF THe

worLd assocIaTIoN For


pLasTIc sUrGeoNs oF cHINese desceNT
6 8 November 2014 HoNG KoNG
www.wapscd2014.orG.HK

Pre-congress WorkshoPs (5 noVeMBer 2014)

workshop 1 - Fillers
workshop 2 - botulinum Toxin
workshop 3 - Non-invasive body contouring
workshop 4 - Non-invasive Face Lifting and skin resurfacing

ProgrAMMe hIghLIghTs
Aesthetic

cosmetic eyelid surgery


cosmetic breast surgery
rhinoplasty
Facelift & Threadlift
abdominoplasty
Liposuction & body contouring
Fat Grafting & stem cells
skin Laser surgery
Toxin & Fillers

FAcULTy MeMBers

reconstructive

Head & Neck surgery


Facial skeleton surgery
craniolfacial/cleft surgery
breast reconstruction
Flaps & microsurgery
Lymphovasular anomalies
wound & Tissue repair
Training in plastic surgery
advances in plastic surgery

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Malaysia

Uk

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Lay-hooi Lim

david Lam
Tiew Teo

canada

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cho pang

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Foad Nahai
Lee pu
christine rohde
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June wu
Jack Yu
Toni Zhong

korea
dae-hwan park

IMPorTAnT DATes
deadline for abstracts submission:
deadline for early bird registration:

regIsTrATIon
10 august 2014
1 september 2014

please register online: www.wapscd2014.org.hk


doctors of all specialties and nurses are welcome to attend

VenUe

enqUIry

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