Medical Tribune December 2014 REG

8/10/2019 Medical Tribune December 2014 REG

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DECEMBER 2014

FORUM

Funding forsmoking cessation

campaigns disclosures matter

FEATUREEmerging trends

in preeclampsia

DRUG

PROFILE

Inhaled fluticasonefuroate /vilanterol for the

management of

stable COPD

CONFERENCE

COVERAGE

Making a casefor adiponectin in

diabetes and its

complications

Audiovisual aidsan effective learning tool

for new parents


2/33

DECEMBER 2014 2

LIANNE COWIE

Interactions with caregivers during the first fewyears of life are crucial for the psychosocialdevelopment of children, and programs aimed

at promoting parent-child interactions can be an

important tool for modifying parental knowledge

regarding effective care practices.

A recent study showed that early exposure to

an audiovisual aid (when the infant was 1 month

of age) altered parental knowledge regarding

such practices, whereas exposure at a later

point (age 7 months) altered parental attitudes.

[BMC Paediatrics2014;14:222]

Our results support the idea that audiovisual

materials, if properly designed and adminis-

tered, can be an effective complementary tool

in programs aimed at supporting parents, par-

ticularly when dealing with their first baby, said

the study authors, led by Dr. Anna Roia, Institute

for Maternal and Child Health, IRCCs Ospedale

Infantile Burlo Garofolo, Trieste, Italy. They also

provide useful insight about the different ben-

efits of using such visual aids at different times

during the first year of the baby.

The researchers contacted a convenience

sample of 127 families living in the area imme-

diately after birth while the mother and infant

were still in the maternity ward. Of the families

who agreed to participate, 53 were randomly as-

signed to the early intervention group and 52 to

the late intervention group.

The intervention

consisted of a video

addressing four spe-

cific activities related

to early child develop-

ment: reading aloud to

the baby, early expo-

sure to music, and pro-

motion of early social-

ization for the parents

and their children. The

video was delivered

via a home visit by a

psychologist. Ninety-nine families (52 in the ear-

ly and 47 in the late group) completed the study.

Parents in the early intervention group more

frequently reported modification of their knowl-

edge relating to the importance of early reading

aloud and infant socialization. Parents in the late

intervention group more frequently reported the

acquisition of positive attitudes towards early

reading aloud, early exposure to music, and pa-

rental socialization.

[T]he importance of an appropriate setting

of administration, ideally through a home visit as

in our study, cannot be overlooked, concluded

the authors. This aspect may be even more

important when dealing with population groups

which, due to specific cultural or social reasons,

are more difficult to reach out to and yet are

those that would yield the greatest benefit from

such interventions.

Audiovisual aids an effective

learning tool for new parents

A recent study supportsthe use of audiovisualprograms for new parents.


3/33

DECEMBER 2014 3

ELVIRA MANZANO

Anew guideline from the American Collegeof Physicians (ACP) recommends increas-ing fluid intake for patients who have had kidney

stones, and pharmacotherapy if increased fluid

alone is inadequate, to prevent stone recurrence.

Increased fluid intake spread throughout the

day can decrease the stone recurrence by at

least half with virtually no side effects, said Dr.

David A. Fleming, ACP president.

The goal for increasing fluid intake is to im-

prove urine output to a minimum of 2L a day. For

patients who fail to reduce stone formation de-

spite this approach, monotherapy with a thiazide

diuretic, citrate, or allopurinol may be considered.

[Ann Intern Med2014;161:659-667]

The evidence for both recommendations was

classified as low to moderate quality.

Kidney stones (nephrolithiasis) form when

crystals or substances that are normally pres-

ent in the urine become highly concentrated,

said guideline author Dr. Amir Qaseem from

the University Health System of Pennsylvania in

Philadelphia, Pennsylvania, US. In most cases,

the stones consist of calcium oxalate and/or cal-

cium phosphate, or other substances such as

uric acid, struvite, and rarely, cystine. The lifetime

prevalence of kidney stones is 13 percent in men

and 7 percent in women. Five-year recurrence

rate can reach up to 50 percent, if left untreated.

The guideline is based on published studies

on kidney stones from January 1948 through

March 2014. The clinical outcomes evaluated

for the guideline were symptomatic stone recur-

rence, pain, urinary tract obstruction with acute

renal impairment, infection, procedure-related ill-

ness, emergency department visits, hospitaliza-

tions, quality of life, and end-stage renal disease.

Intake of fluids was one of the dietary interven-

tions evaluated.

In one study, patients with calcium stones

who increased their fluid intake to achieve >2L

of urine per day had less composite stone re-

currence within 5 years compared with the

control group (12.1 versus 27 percent). [J Urol

1996;155:839-843] Another study showed that

increased fluid intake resulted in a non-statisti-

cally significant decrease in stone recurrence

compared with no treatment (8 vs 56 percent)

within 2 to 3 years of follow-up. [Urol Res

2006;34:184-189]

The authors, however, cautioned that drink-

ing extra fluids may not work for some patients

with kidney stones. It is also contraindicated in

heart failure patients. With regard to pharma-

cologic treatments, combination therapy with

a thiazide diuretic, citrate or allopurinol was no

more beneficial than any of these agents taken

alone. Some of the adverse effects associated

with these drugs included fatigue, gastrointesti-

nal problems, headache and anemia.

New guideline for preventing kidney

stone recurrence


4/33

DECEMBER 2014 FORUM 4

Funding for smoking cessation

campaigns disclosures matter

An increasing awareness of the harms of tobacco smoking has coincided with the growth of

a new industry smoking cessation campaigns worldwide. With a high proportion of the

worlds tobacco smokers, the Asia Pacific region is not an exception. A question of ethics now

arises with regards to smoking cessation campaigns, which are being increasingly funded

by pharmaceutical companies, in particular those with interests in nicotine replacement

therapies (NRTs).

CHUAH SU PING

Akey challenge faced by anti-smoking bod-ies is that there is a lack of funds for theircampaigns. There is still a lack of awareness of

the risk factors associated with tobacco smok-

ing, and smoking in general is often viewed as

an issue of personal behavior, which is inaccu-

rate, said Dr. Carolyn Dresler, associate direc-

tor for Medical and Health Sciences in the Office

of Science at the US FDA Center for Tobacco

Products Office. Its not just a behavioral prob-

lem were dealing with; its a chemical addiction

nicotine addiction which is a serious disease.

With regards to the relationship between

the pharmaceutical industry and smoking ces-

sation, to me it depends a little on the duplicity

of the industries involved, said Dresler. In my

opinion, the tobacco industry are convicted liars,

but we cannot ignore that the pharmaceutical in-

dustry has had similar issues. However, the mis-

sion of pharmaceutical companies is ostensibly

for good, whereas the product produced by the

tobacco industry, when used as indicated, kills.

Dresler noted that she was a former medical

director of research and development for NRT

products at a leading pharmaceutical company.

Market forces at play

It is true that both smoking as well as smok-

ing cessation are driven by market forces, said

Dresler, highlighting a recent case in which a US

District Court in Washington D.C., ruled against

the US FDA in favor of cigarette makers Loril-

lard Inc and Reynolds American Inc, who had

sued the FDA in 2011, alleging conflicts of inter-

est and bias by several members of the panel

tasked with advising the FDA on tobacco-relat-


5/33

DECEMBER 2014 FORUM 5

ed issues. Their lawsuit specifically alleged that

some committee members had conflicts of in-

terest as they were paid expert witnesses, and

possessed financial ties to pharmaceutical com-

panies that manufactured smoking-cessation

products.

In his ruling, which took place in July 2014,

US District Judge Richard Leon said the FDA

had erred in determining that the members did

not have conflicts of interest and therefore, the

agencys appointment of those members was

arbitrary and capricious, and tainted both the

panel and its work. The FDA was ordered to

reconstitute the tobacco panel and the use of

its 2011 report on menthol cigarettes has been

barred. [Available at https://ecf.dcd.uscourts.

gov/cgi-bin/show_public_doc?2011cv0440-82.

Accessed on 13 December 2014]

It is difficult to separate conflict of interests

and biases from something like smoking cessa-

tion, especially when theres funding involved,

Dresler admitted. This is because, as I men-

tioned, there is already very little funding being

allocated for smoking cessation campaigns,

said Dresler. When you put it up against some-

thing as large as the tobacco industry, with their

large resources, and their ability to influence

government and political decisions, its an uphill

battle.

Is there an ideal source of funding?

If you have sources of funding from non-

pharmaceutical organizations, such as non-gov-

ernmental organizations or the health ministry,

that would be best, said Associate Professor Dr.

Mohamad Haniki Nik Mohamed, Deputy Dean

at Kulliyyah of Pharmacy at the International Is-

lamic University Malaysia. However, given the

limitations, sometimes we do have to consider

accepting funding from pharmaceutical compa-

nies to facilitate certain events. In such cases,

the funding company should not become in-

volved in the planning of the advocacy program

it should be completely independent.

The worst thing to do, he stressed, would

be to accept funding from the tobacco indus-

try, for whatever purpose. Dr. Zarihah Zain of

the Disease Control Disease, Ministry of Health

Malaysia, agrees. According to Article 5.3 of

the Framework Convention on Tobacco Control

(FCTC), parties to the Convention should not

partner with tobacco corporations to promote

public health, nor accept the tobacco indus-

trys so-called corporate social responsibility

schemes, which are really just marketing by an-

other name, she said.

The Article 5.3 Guidelines also outlined trans-

parency measures including, Disclosure of cur-

rent or previous work with tobacco industry by

applicants for government positions related to

health policy, and of plans to work for tobacco

industry by former public health officials. Also,

disclosure of tobacco industry activities, includ-

ing: production, manufacture, market share,

revenues, marketing, expenditures, philanthro-

py with penalties for providing false or mis-

leading information. [Available at www.fctc.org/

media-and-publications/media-releases-blog-

list-view-of-all-313/industry-interference/718-ar-

ticle-53-framework-convention-on-tobacco-con-

trol-tobacco-industry-interference. Accessed on

14 December 2014.]


6/33


7/33

DECEMBER 2014 NEWS 7

Discussing preferences critical

during end-of-life care

RADHA CHITALE

End-of-life care discussions are tricky andnecessary, but a new survey reveals theseconversations are not happening, based on

what patients and their families say their end-

of-life goals are versus what they are advised by

experts. [CMAJ2014. doi:10.1503/cmaj.140673]

Our findings could be used to identify impor-

tant opportunities to improve end-of-life com-

munication and decision-making in the hospital

setting, said lead researchers Dr. John You, as-

sociate professor of Medicine and Clinical Epi-

demiology and Biostatistics at McMaster Univer-

sity in Hamilton, Ontario, Canada.

The current literature regarding end-of-life

care discussions suggests 11 topics that are

considered most important by doctors, with

little to no input from patients or families, the re-

searchers noted.

However, when the researchers surveyed real

patients (mean age 81) and families about which

topics they felt were most important, opinions

converged to identify the following five areas:

- preferences of care in event of life threatening

illness

- patient values (what is important when consid-

ering healthcare decisions)

- prognosis of illness

- fears or concerns

- additional questions regarding care

However, it was clear that halting discussion

there was not necessary. Patient satisfaction

scores were directly proportional to how much

physicians were willing to discuss end-of-life

care. Patient satisfaction improved as they cov-

ered more topics and as the number of times

they had such discussions increased.

The Canada-based survey included 233 el-

der adults in hospital who had serious illnesses

and 205 of their family members.

The researchers found that end-of-life care

discussions occurred in less than one-third of

cases, sometimes as little as 1.4 percent of the

time. This appeared to support national data

showing that rates of cardiopulmonary resus-

citation (CPR), dying in-hospital, and intensive

care unit deaths are rising among elderly pa-

tients with serious disease, despite the fact that

80 percent of these patients prefer a less ag-

gressive and more comfort-oriented end-of-life

care plan that does not include CPR, the re-

searchers said.

Other topics of discussion on the 11-item list

that patients did not identify in their top five in-

cluded facilitating access to legal documents to

record patient wishes and providing information

about the outcomes, risks, benefits of comfort

care. [Med J Aust 2007;186:S77,S79,S83-108;

Advance Care Planning. Concise Guidance

to Good Practice Series, No 12. London (UK),

2009]


8/33


Mental disorders may cause cardiac

symptoms

RADHA CHITALE

Depression, anxiety and other psychologicaldisorders are known to influence cardiacactivity and can result in cardiac symptoms even

when tests show patients to be free of heart dis-

ease.

Despite this high importance, in patients

with non-cardiac chest pain, mental disorders

are often diagnosed too late, because cardiolo-

gists without psychosomatic experience lack

uncomplicated diagnostic tools to detect them

accurately, said researchers from University

Hospital Dresden in Germany, who surveyed

disease-free patients about their mental state in

order to determine the extent of the correlation.

About 20 percent of people who suffer from

cardiac symptoms such as chest pain or short-

ness of breath do not have heart disease but

they are just as likely to use healthcare resourc-

es and can have lower quality of life. Early iden-

tification could alleviate this problem.

The trial included 235 patients with at least

one cardiac symptom chest pain (55.3 per-

cent), dyspnea (35.4 percent), or palpitations

(39.4 percent) who were assessed for and

did not have coronary artery disease (CAD).

[Open Heart 2014;1:e000093.doi:10.1136/

openhrt-2014-000093]

These patients were given a questionnaire

that tested for general and heart-related anxiety

and depression, idiopathic pain with a poten-

tially psychological root, hypochondriac ten-

dencies, and quality of life in relation to physical

and mental health before and 6-8 months after

undergoing an invasive coronary angiography.

The test revealed that 8.7 percent of patients

reported severe cardiac symptoms prior to

coronary angiography and 28 percent reported

moderate symptoms.

However, even after CAD exclusion following

angiography, 70 percent of patients reported

persistent symptoms.

Compared to a population of healthy adults,

general anxiety was higher by 37 percent

(p


9/33


by study participants compared to the normal

population.

The researchers noted they were unable to

determine cause and effect between psycho-

pathological symptoms and cardiac symptoms

or vice versa. They also lacked information

about gastrointestinal disorders, skeletal condi-

tions or other non-cardiac causes of chest pain.

However, the study did suggest patients with

non-cardiac chest pain should be offered psy-

chological or psychiatric support early in order

to begin psychosomatic therapy, which may

prevent patients from seeking pharmaceutical

or procedural solutions, and to improve their

quality of life.

Without training, cardiologists are more likely

to overlook psychosomatic symptoms, but the

researchers suggested the 120-minute ques-

tionnaire that takes 15 minutes to evaluate by a

nurse was a practicable solution for inpatients

and outpatients.

These [standardized questionnaires] may

prevent repeated utilization of the healthcare sys-

tem and this could help to reduce costs for these

patients due to initiation of an early psychoso-

matic therapy, the researchers said.


10/33


Neuroticism, long-term stress

linked to higher risk of Alzheimers

in women

ELVIRA MANZANO

Women who worry a lot and cope poorlywith stress may be at an increased risk ofdeveloping Alzheimers disease (AD) later in life,

research suggests.

A study of 800 women in Sweden followed

for 38 years showed that women with the high-

est scores on neuroticism scale and had expe-

rienced long-term distress in midlife were twice

as likely to develop AD than those with the

lowest scores. [Neurology 2014; pii:10.1212/

WNL.0000000000000907;E-pub ahead of print]

Neuroticism is the enduring tendency to be

in a negative emotional state. People with neu-

rotic personality may perceive daily run-of-the-

mill situations as alarming or depressing. They

suffer from negativity, feelings of guilt, anxiety,

envy and anger more frequently and more se-

verely than other people and have difficulty

managing stress, although they are in touch

with reality.

We have shown in this study that midlife

neuroticism is associated with increased risk of

AD, and that distress mediates this association.

Clearly, there was a clear statistical correlation in

those who had been exposed to a long period

of stress, said Johansson. It is the stress itself

that is harmful. A person with a neurotic tenden-

cy is more sensitive to stress than other people,

said lead researcher Dr. Lena Johansson from

the Sahlgrenska Academy at Gothenburg Uni-

versity in Molndal, Sweden.

Using the Eysenck Personality Inventory

scale, women were assessed of their dominant

personality traits (ie, extraversion vs introversion

and neuroticism vs stability). Dementia was di-

agnosed according to DSM-III-R criteria, based

on information culled from neuropsychiatric ex-

aminations, hospital records, and registry data.

During the study period, 153 women who had

neurotic tendencies at midlife had developed

some types of dementia, 104 of which had AD.

Advancing age, family history, and genetics

are known risk factors for AD and other demen-

tia-related disorders. This is the first study to

show a link between personality and AD, said

Johansson. However, the finding does not sug-

gest that neuroticism alone could increase the

risk of AD.

Personality could determine behavior, life-

style and how we react to stress. Ultimately, all

these may significantly affect the risk of develop-

ing AD.

She said future studies should exam-

ine whether this group of women will re-

spond well to interventions. It remains to be

seen whether neuroticism could be modi-

fied by medical treatment or through lifestyle

changes.


11/33

DECEMBER 2014 RESEARCH REVIEWS 11

Reducing external knee adduction moment

(EKAM), a surrogate measure of medial

joint loading, by wearing lateral wedge insoles

does not reduce knee pain in patients with

knee osteoarthritis, according to a multination-

al group of researchers.

In their study, 70 patients (mean age 60.3

years) with radiographically confirmed pain-

ful medial knee osteoarthritis underwent a gait

analysis whilst walking in a control shoe, a

typical lateral wedge insole, and a supported

wedge insole.

The researchers compared changes in

EKAM and knee pain scores, and found that

significant reductions in pain were only ob-

served when patients were using the medial

supported lateral wedge insole (-6.29 per-

cent vs control). However, there was no differ-

ence in pain reduction between patients who

experienced a decrease in EKAM and those

who did not. Moreover, patients who experi-

enced consistent major reductions in EKAM

did not report a consistent reduction in knee

pain.

Jones R et al. The relationship between reductions

in knee loading and immediate pain response whilst

wearing lateral wedged insoles in knee osteoarthritis. J

Orthop Res 2014;32:1147-1154.

Reducing knee load with lateral wedge insoles does not

alleviate knee OA pain


12/33

DECEMBER 2014 RESEARCH REVIEWS 12

Iodothyronine deiodinases are key regulators

of thyroid hormone metabolism and since

thyroid hormones are functionally active in nu-

merous tissues, deiodinase polymorphisms

have the potential to affect multiple clinical

endpoints.

In a recent systematic review, researchers

evaluated the relationship between iodothyro-

nine deiodinase polymorphisms and a variety

of parameters. Eligible studies were identified

by searching the Pubmed, EMBASE, Web of

Science, Cochrane Library, CINAHL, Academic

Search Premier, and Science Direct databases

for articles published up to 13 August 2013.

The researchers found that deiodinase type

1 (D1) polymorphisms showed a moderate-to-

strong relationship with thyroid hormone pa-

rameters, insulin-like growth factor 1 produc-

tion, and risk for depression. D2 variants were

correlated with thyroid hormone levels, insulin

resistance, bipolar mood disorder, psychologi-

cal well-being, mental retardation, hyperten-

sion, and risk for osteoarthritis, and one D3

polymorphism was associated with a risk for

osteoarthritis. However, the researchers noted

that the clinical implications of these associa-

tions are far from clear and may vary among

different populations. They commented that

further research is required to determine the

exact role of deiodinase polymorphisms and

their potential as therapeutic targets.

Verloop H et al. Genetic variation in deiodinases: a sys-

tematic review of potential clinical effects in humans. Eur

J Endocrinol 2014;171:R123-R125.

Clinical effects of deiodinase polymorphisms studied


13/33

DECEMBER 2014 DRUG PROFILE 13

COPD is a leading cause of mortality worldwide and deaths from COPD are expected to

keep rising over the coming decade. In Asia, the burden of COPD is currently higher than in

the West. This article profiles a novel once-daily combined inhaled corticosteroid/long-acting

beta 2-agonist formulation fluticasone furoate / vilanterol and its use in the management

of COPD.

Inhaled fluticasone furoate /

vilanterol for the management

of stable COPD

Naomi Adam, MSc (Med), Category 1 Accredited

Education Provider (Royal Australian College

of General Practitioners)

Introduction

Chronic obstructive pulmonary disease

(COPD) is a term used to describe chronic

lung diseases that limit airflow, and includes

the conditions previously known as chronic

bronchitis and emphysema. Symptoms include

breathlessness, chronic cough and sputum

production.

The main risk factors for the development of

COPD include cigarette smoking, air pollution

(both outdoor and indoor) and occupational

hazards such as vapours, fumes and irritants.

In high-income countries, smoking is the pre-

dominant cause whereas in low-income coun-

tries indoor air pollution associated with the

use of fuels for cooking and heating produces

most COPD burden. [WHO Fact Sheet No 315.

Chronic obstructive pulmonary disease]

COPD is now the fifth-most common cause

of death worldwide and total deaths from COPD

are projected to increase by more than 30 per-

cent in the next 10 years.

In Asian countries COPD burden is higher

than in their Western counterparts, with more

deaths, years spent living with disability, and

years of life lost. This can be attributed to high

tobacco smoking rates, poor quality of outdoor

air and the use of biomass fuels indoors. [Int J

Tuberc Lung Dis 2008;12:713-717]

The diagnosis of COPD in symptomatic pa-


14/33


tients is made on the basis of spirometry, which

measures the presence and severity of airflow

obstruction: COPD is characterised by airflow

obstruction that is not fully reversible on the

administration of bronchodilators. [Ann Intern

Med2011;155:179-191]

The priorities in management of COPD in-

clude smoking cessation and using effective

inhaled therapy. In patients with stable disease

who remain breathless or experience exacer-

bations despite use of short-acting bronchodi-

lator reliever therapy, guidelines recommend

the use of maintenance therapy. Those with a

forced expiratory volume (FEV) 50 percent of

predicted should be given either a long-acting

beta-2 agonist (LABA) or long-acting musca-

rinic antagonist (LAMA). When FEV falls below

half that predicted, patients should be given

either a LABA with an inhaled corticosteroid

(ICS) in a combined inhaler or a LAMA. [NICE.

Management of chronic obstructive pulmonary

disease in adults in primary and secondary

care. June 2010]

The combination of ICS and LABA in a single

device is well tolerated and results in improved

FEV, quality of life and respiratory symptoms

in stable COPD patients. Over time, there have

been progressive improvements in available

LABA and ICS therapies, allowing the develop-

ment of treatment delivered in once-daily, sin-

gle device format. [Int J COPD2014;9:249-256]

Fluticasone furoate / vilanterol

Mode of action

Fluticasone furoate is a corticosteroid with

anti-inflammatory activity. It is highly potent,

binding more strongly to the glucocorticoid re-

ceptor than other commonly used ICS, includ-

ing fluticasone propionate, mometasone fu-

roate, budesonide and ciclesonide. Fluticasone

furoate also has the largest cellular accumula-

tion and slowest rate of efflux among these ICS,

leading to prolonged efficacy and the potential

for once-daily dosing. [Am J Physiol Lung Cell

Mol Physiol 2007;293:L660L667]

Vilanterol is a long-acting beta2-adrenergic

agonist (LABA) that stimulates intracellular ad-

enyl cyclase to increase levels of cyclic-3,5-

adenosine monophosphate (cAMP). Increased

cAMP levels lead to relaxation of bronchial

smooth muscle and inhibition of release of

mediators of hypersensitivity. [Breo Ellipta Pre-

scribing Information]

Clinical efficacy

Two clinical trials of 1 year in duration have

demonstrated the effectiveness of fluticasone

furoate / vilanterol compared with vilanterol

alone. The studies enrolled patients aged 40

years and over, with a history of COPD and

smoking (10 pack-years) and history of one or

more moderate-to-severe exacerbations in the

In high-income countries, smoking

is the predominant cause whereas

in low-income countries indoor air

pollution associated with the use

of fuels for cooking and heating

produces most COPD burden


15/33


previous year (approximately 1,300 patients in

each study). Subjects were randomized to ei-

ther 25 g vilanterol alone or 25 g vilanterol

combined with either 50 g, 100 g or 200 g

fluticasone furoate once daily. Combination

therapy provided a significant reduction in the

primary endpoint of annual rate of moderate-

to-severe COPD exacerbations. [Lancet Respir

Med2013;1:210-223]

Two other trials have examined the effect of

fluticasone furoate / vilanterol on lung function

compared with placebo and each component

alone. Both of these were 24 weeks in duration

and enrolled patients with stable moderate-to-

severe COPD. Acute (04 hours post-dose) and

trough (2324 hours post-dose) effects on lung

function were assessed. All active treatments

improved FEV, and confirmed that fluticasone fu-

roate / vilanterol results in significant, sustained

bronchodilation. [Respir Med 2013;107:550-

559, Respir Med2013;107:560-569]

Adverse effects

The treatment of patients with stable COPD

with fluticasone furoate / vilanterol in combina-

tion is usually well tolerated. Common side ef-

fects (occurring in 5 to 10 percent of patients)

include nasopharyngitis, upper respiratory tract

infection, headache, dysphonia and oropha-

ryngeal candidiasis. In the long-term clinical tri-

als of fluticasone furoate / vilanterol, fractures

and pneumonia were more common with the

combination therapy. Although the overall rate

of pneumonia was low, there were eight deaths

due to pneumonia in the fluticasone furoate /

vilanterol group and none with monotherapy.

As with other inhaled LABAs, vilanterol is as-

sociated with clinically significant cardiovascu-

lar effects such as increased heart rate, blood

pressure and QT interval prolongation. It should

therefore be used with caution in patients with

arrhythmias, acute coronary syndromes or

heart failure. In healthy subjects however, the

safety of single and repeat doses has been

demonstrated, with no deleterious effects upon

ECG measurement, QT interval or blood glu-

cose or potassium. [Int J COPD2014;9:249-56]

Dose and administration

Fluticasone furoate combined with vilanterol

is the first once-daily ICS/LABA combination to

be available (marketed under the trade names

Relvarand Breo). It is available in a new dry

powder inhaler delivery device (Ellipta) which

is designed for simplified usage. The dose for

maintenance therapy of COPD is one inhala-

tion daily, which delivers 100 g of fluticasone

furoate and 25 g of vilanterol. [Breo Ellipta

Prescribing Information]

Fluticasone furoate combined

with vilanterol is the first once-

daily ICS/LABA combination to

be available


16/33

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DECEMBER 2014 FEATURE 17

Preeclampsia is a hypertensive complica-tion of pregnancy, characterized by highblood pressure as well as possible kidney

damage. Typically, preeclampsia occurs after

20 weeks of pregnancy and, if untreated, can

pose significant threats to the mother and the

baby, especially if birth is premature. While the

symptoms of preeclampsia go away following

birth or more specifically, removal of the pla-

centa the condition leaves mothers with long-

term health risks.

The incidence rate of preeclampsia in devel-

oped nations is between 2 to 5 percent, higher

in developing countries. While the overall inci-

dence of preeclampsia is not high, the conse-

quences are severe. In Europe, for example,

the incidence of preeclampsia is about 3 per-

cent, but 25 percent of perinatal mortality is

caused by preeclampsia.

Importantly, preeclampsia is unpredictable.

Emerging trends in preeclampsia

Professor Holger Stepan

Director of ObstetricsUniversity Hospital LeipzigLeipzig, Germany

Preeclampsia is unpredictable. The cause of disease, aggressiveness, and speed of escalation varies from patient topatient.


18/33


The cause of disease, aggressiveness, and

speed of escalation varies from patient to pa-

tient. For example, a pregnant woman in week

24 could be feeling fine but wakes up one

morning with some abdominal pain and if there

are complications, her situation can shift to very

severe within a day.

Predicting preeclampsia

The many other symptoms of preeclampsia

can be equally non-specific: excess protein in

the urine, headaches, blurred vision, nausea,

low platelet levels, shortness of breath, swell-

ing.

Other cases of preeclampsia may be less

severe. The problem is that a doctor with nor-

mal measures to assess pregnancy cannot dif-

ferentiate between normal, moderate, and high

danger. Those at risk include very young preg-

nant women (teenaged) or mature mothers

(over 40 years), twin pregnancies, overweight

women, women with kidney disease, and preg-

nant women with poor placental perfusion.

Early diagnosis is challenging, and in the

past doctors were only able to identify pre-

eclampsia as it occurred. However, the last de-

cade has seen the discovery of novel biomark-

ers that show promise both for early detection,

risk stratification and management.

A significant breakthrough in understand-

ing preeclampsia came about in 2002, when

Dr. Ananth Karumanchi, a kidney specialist at

Harvard University in Boston, Massachusetts,

US, observed the role of two proteins prior to

the onset of preeclampsia. During pregnancy,

the placenta releases placental growth factor

(PIGF), an angiogenic factor from the VEGF

family (a large group of proteins responsible for

blood vessel growth). Soluble fms-like tyrosine

kinase-1 (sFlt-1) is an antagonist to PIGF, bind-

ing to it and inhibiting cell growth.

In a normal pregnancy, these two proteins

are in balance ensuring the health of mother

and baby. Karumanchi showed that pregnant

women with preeclampsia have too much sFlt-

1 circulating in their blood, and too little PIGF.

This fundamentally changed the view of pre-

eclampsia and confirmed it as a state of imbal-

ance between angiogenic and anti-angiogenic

factors.

In addition to blood pressure monitoring or

proteinurea measures, blood tests for these

biomarkers have the potential to identify wom-

en at high risk of preeclampsia earlier in the

pregnancy, before the onset of the disease.

These types of biomarker tests are also

helpful for differential diagnosis. Typically, one

out of five women presenting with preeclamptic

symptoms will go on to develop preeclampsia.

If you can tell four of those women that they

will not develop preeclampsia, the benefit is tre-

mendous.

The emerging importance of a

biomarker ratio

A number of studies have shown that the ra-

tio of sFlt-1 to PlGF is more useful than either

measure alone. The ratio has proven highly

useful in helping clinicians identify which preg-

nant women are at highest risk and need to be

referred for timely interventions.

A European study of women with differing hy-


19/33


pertension-related conditions and normal con-

trols (n=630) has shown that the sFlt-1/PIGF

ratio could be used to differentiate the various

types of hypertensive diseases in pregnancy.

The value was also found to correlate with the

time span from diagnosis until delivery; women

with the highest ratios had the shortest time

interval from diagnosis until delivery with the

most aggressive disease course while women

with the lower ratios had a longer time interval

and less aggressive disease.

At the moment, the only cure for preeclamp-

sia is removing the placenta. Simply lowering

blood pressure with antihypertensive medica-

tions will not stop preeclampsia because it is

driven by placental proteins. The disease seems

to originate from the placenta, if the placenta is

not removed during delivery, preeclampsia will

continue. And it is impossible to remove the pla-

centa without delivering the baby.

A specialized center with pediatricians expe-

rienced in premature babies is critical for pre-

eclamptic women. The goal of management is

to monitor maternal and fetal heart rate, well

being, ultrasound, and so on to pinpoint the

correct time for delivery too early and there

is risk for the baby, too late and there can be

complications for both mother and baby.

These placental proteins driving preeclamp-

sia are future targets for therapies but for now,

tracking their concentration can help indicate

when a woman can safely deliver.

New therapeutic approaches

for preeclampsia

Given the new understanding of preeclamp-

sia as a state of angiogenic imbalance, treat-

ments aimed at interfering with the effects of

sFlt-1 to restore the balance have shown initial

promise.

Extracorporeal removal of sFlt-1 from the

blood of a pregnant woman has shown favor-

able initial results. The future is in determining

whether the technique prolongs pregnancy

and improves maternal and fetal outcomes in a

larger patient population.


20/33


Informed consent

Dr. Eugene WongConsultant Orthopedic and SpineSurgeonAdjunct Assistant ProfessorPerdana University Graduate School of

MedicineSerdang, Selangor

Patients should be educated prior to entry into clinical trials so they may give informed consent.

Informed consent is defined as approval orpermission given by the patient based onknowledge of the procedure or treatment to be

performed. The information includes the risks

and benefits, as well as alternatives to the pro-

posed treatment.

Patients beliefs, culture, occupation or other

factors have a bearing on the information they

need in order to reach a decision. Touching a

person without consent constitutes battery and

putting a person in fear of being touched with-

out consent is an assault.

Informed consent differs from implied con-

sent. Consent is implied for gathering informa-

tion by history taking and performing neces-

sary examinations. Subsequent treatment plans

need to be discussed with the patient and in-

formed consent taken.

There are two types of consent. The first is


21/33


the expressed consent, either oral or written,

given by the patient to undergo a specific pro-

cedure or treatment. Implied consent is inferred

from circumstances. It is rarely documented and

is relied upon for care or treatment that is rou-

tine and does not involve significant risks to the

patient. The doctor performing the procedure

or administering the treatment in question is re-

sponsible for engaging the patient in the con-

sent process.

Competence requires patients ability to un-

derstand the consequences of their decision and

the need of freedom from coercion. It requires

the ability to understand the proposed treatment

and make an informed decision. Competence is

usually assumed unless there are indications to

the contrary. Only an autonomous person can

give informed consent. If the patient is incom-

petent, proxy consent is allowed, but no more

than minimal risk to the patients is allowed. The

reasonable person and best interest judgment

standards need to be applied. A risk, even if it

is a mere possibility, should be regarded as sig-

nificant if its occurrence can cause serious con-

sequences.

Adequate decision-making capacity is the

ability to understand, evaluate and communicate.

As a rule, consent should not be obtained from

a sedated or anesthetized patient for an elective

procedure. Emergency treatment without con-

Competence

Adequate Disclosure

Adequate Understanding / Comprehension

Voluntary Decision

Consent

Table 1: Requirements for informed consent.Respects autonomy

Respects the right to control what happens to onesbody

Respects the right to control access to the self

Promotes greater social goods

Promotes trust between doctor and patient

Reduces liability and malpractice claims

Can be justified at least on utilitarian, deontological,and rights grounds, also on virtue ethics grounds.

Table 3: Justification for informed consent.

Difference in the knowledge base of the doctor andpatient

Patients are compromised by illness, anxiety, etc

Language of probabilities is unfamiliar to lay-persons

Takes too much time

Some patients just dont want to know

Table 4: Obstacles to informed consent.Nature of the procedure (diagnostic or therapeutic)

Probable complications

Risks involved, especially if they are severe andlikely to occur v

Expected benefits of the procedure

Alternatives to the procedure, along with their risksand benefits

Probable outcomes

Table 2: Features of adequate disclosure.


22/33


Consent

Intentional, the result of deliberation

Free, without coercion

Authentic, from ones own values and desires

Conditions for informed consent

Information about:

Nature of the research

Therapeutic or non-therapeutic

Risks

Benefits

Whos doing it competence of investigators

What will be done to the subject

Privacy and confidentiality of information

Right to withdraw without penalty

Provisions for adverse circumstances

Competence/decision-making capacity

Informed consent presupposes competence

Competence is determined in relation to the task

at hand

Legal competence/moral competence

Conditions for competence:

- some degree of self-knowledge and self-

awareness- able to process information

- able to comprehend information

- able to restate information in ones own terms

- able to act from stable set of values

- free from acute anxiety, acute depression and

denial

Table 6: Informed consent Research on human subjects.

Risks/Benefits

Alternatives

Second opinion

Competence of doctor, team, institution

Nature of procedure

Life after recuperation, bodily and psychologicalchanges

Cost

Who is involved in the treatment?

Patients role in procedure, recovery

Conflicts of interest

Table 5: Informed consent for treatment.

sent may be undertaken if the patient is in im-

mediate need of treatment. The patient is unable

to provide consent because of physical or mental

impairment or because the patient is a minor. Im-

plied consent is required in cases of emergency

treatment, where it is presumed that the patient

would have consented to treatment if it is neces-

sary to save his life or from serious harm.

Research involving clinical trials of drugs or

treatments and research into the causes of, or

possible treatment for, a particular condition, is

important in increasing doctors ability to provide

effective care for present and future patients.

The benefits of the research may, however, be

uncertain and may not be experienced by the

person participating in the research. It is particu-

larly important that you ensure that the research

is not contrary to the individuals interests, the

participants understand that it is research and

that the results are not predictable.

Giving treatment without consent is a failure to

respect the patients autonomy and violates an

individuals right of self-determination. The con-

sent form is for patients to acknowledge that the

nature and purpose of treatment has been fully

explained, understood and consented to. Poor

handling of informed consent can lead to com-

plaints, medico-legal litigation and discipline for

negligence.


23/33

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24/33

DECEMBER 2014 CONFERENCE COVERAGE 24

CHUAH SU PING

There was a strong emphasis on the roleof tobacco smoking in the developmentof lung cancer at this years Asia Pacific Lung

Cancer Conference (APLCC) in Kuala Lumpur,

Malaysia. However, discussion regarding anoth-

er key risk factor outdoor air pollution was

strangely absent from the agenda.

The ASEAN region has 10 percent of the

worlds smokers, with Indonesia making up 51

percent of the distribution in the region, followed

by the Philippines with 13.6 percent and Viet-

nam with 12 percent, said Dr. Tara Singh Bam,

who represents the International Union Against

Tuberculosis and Lung Disease (The Union) in

Indonesia. He noted that here are approximately

127 million adult smokers in the ASEAN alone.

Smoking is the leading preventable cause

of death in the developed world and quickly be-

coming so in developing countries. Currently,

there are between 5 and 6 million deaths year-

ly in the world, and this figure is expected to

climb to 10 million by around 2025, said Dr.

Carolyn Dresler, associate director for Medical

and Health Sciences in the Office of Science

at the FDA Center for Tobacco Products Office,

US. If a smoker does not quit, then they have

a 50 percent chance of dying from a tobacco-

related disease.

In the Resolution presented at the close of

the conference, the first statement highlights

that Tobacco is a key risk factor for lung can-

cer claiming about 1.6 million lives globally ev-

ery year. The Resolution notes that complete

implementation of the WHO Framework Con-

vention on Tobacco Control (WHO FCTC) is

the most effective way forward for prevention

of lung cancer, and the APLCC supports full

implementation of the WHO FCTC especially in

all countries that are party to this treaty. Addi-

tionally, the Resolution noted, Tobacco prod-

ucts should be explicitly excluded from future

international, regional and bilateral trade and

investment agreements.

Air pollution a leading environmental cause

of cancer deaths (WHO, 2013)

In October 2013, the specialized cancer

agency of the WHO, the International Agency

for Research on Cancer (IARC), announced that

it had classified outdoor air pollution as carci-

Asia Pacific Lung CancerConference targets tobacco,

overlooks air pollution

2014 IASLC Asia Pacific Lung Cancer Conference, November 6-8,

Kuala Lumpur, Malaysia


25/33


nogenic to humans (Group 1). This conclusion

was reached by leading experts convened by

the IARC Monographs Programme who, after

thorough review of the latest scientific literature,

concluded that there is sufficient evidence

that exposure to outdoor air pollution causes

lung cancer. [Press release no. 221, 17 October

2013, WHO]

Ambient air pollution (AAP) should also not

be ignored as a major cause of mortality, says

the WHO. In 2012 alone, 3.7 million deaths

globally were attributable to AAP, with about 88

percent of these deaths occurring in low- and

middle-income countries, which represent 82

percent of the world population. [Available at

www.who.int/phe/health_topics/outdoorair/da-

tabases/AAP_BoD_results_March2014.pdf. Ac-

cessed on 12 December 2014]


26/33


KATHLIN AMBROSE

Hypoadiponectenemia in obese individualsplays a pathogenic role in the develop-ment of type 2 diabetes mellitus (T2DM) as well

as its complications, which include coronary ar-

tery disease, ischemic stroke and nephropathy.

Hence, the potential clinical applications of adi-

ponectin as a biomarker for predicting the de-

velopment of T2DM and its cardiovascular com-

plications, plus the development of therapeutic

targets, have been suggested based on cumu-

lative data from multiple studies. These studies

were described extensively by Professor Karen

Siu Ling Lam of the Li Ka Shing Faculty of Medi-

cine, University of Hong Kong.

In a meta-analysis of 13 prospective studies,

which included almost 15,000 subjects, high ad-

iponectin levels were observed to confer a lower

risk of T2DM relative risk of 0.72 per 1-log g/

mL increment in adiponectin levels. This inverse

association was consistently observed across all

populations, said Lam. [JAMA2009; 302:179-

188] In addition, Lam and her colleagues study

of non-diabetics in the Hong Kong Cardiovas-

cular Risk Factor Prevalence Study (CRISPS)

cohort showed that the combined use of serum

adiponectin and tumor necrosis factor-alpha

receptor 2 (TNF- R2) as biomarkers provid-

ed added-value over traditional risk factors for

T2DM prediction. [PloS one2012;7:e36868]

The association between adiponectin and

insulin sensitivity has also been analyzed at

the genetic level, where evidence of a causal

relationship was found in a study of Swedish

men. [Diabetes 2013; 62:1338-1344] This cor-

Making a case for adiponectin

in diabetes and its complications

Diabetes Asia 2014 Conference, October 16-19, Kuala Lumpur, Malaysia

Adiponectin is a protein synthesized and secreted predominantly by adipocytes into the

peripheral blood. Low circulating adiponectin concentrations are associated with a variety of

metabolic diseases and cancers, with recent studies demonstrating the potential of the protein

as various clinical biomarkers and therapeutic targets. Professor Karen Siu Ling Lam from the

University of Hong Kong shared some insights into the latest development in this area.


27/33


responds to an earlier study in the CRISPS

cohort and a subsequent meta-analysis includ-

ing two European studies, which concluded

that the ADIPOQ single nucleotide polymor-

phism (SNP) T45G (rs2241766) independently

predicted persistent hyperglycemia at 5 years

and the development of T2DM. [Diabetologia

2006;49:1806-1815]

The link between adiponectin and T2DM is

taken further with associations found between

the protein and T2DM complications. A study

of a large Caucasian cohort showed that a vari-

ant of the ADIPOQ gene, adipo4 (rs266729),

which results in low adiponectin levels, is as-

sociated with increased carotid intima-media

thickness (CIMT), a marker of atherosclerosis

and a stroke risk factor, suggesting a causal

role of adiponectin in carotid atherosclerosis.

[Stroke 2011;42:1510-1514] This relationship

was also observed in a multi-ethnic population

and was even more marked in those with T2DM.

[Stroke2012;43:1123-1125] Hui et al confirmed

this relationship in a prospective study in the

CRISPS cohort, whereby low serum adiponec-

tin independently predicted progression of ca-

rotid atherosclerosis identified via CIMT incre-

ments over the years. [Metab Syndr Relat Disord

2014 Epub ahead of print] All these suggest that

adiponectin participates in the development of

carotid atherosclerosis. However, this was not

the case in ischemic stroke patients, although

serum adiponectin was indeed lower compared

to controls. A meta-analysis of eight prospec-

tive studies showed that in the long term, serum

adiponectin levels did not predict incidence, but

instead was found to be a good predictor of the

5-year survival rate following the first episode of

ischemic stroke. [Stroke 2014;45:10-17; Stroke

2005;36:1915-1919]

In almost all populations studied, there was

a clear indication that a high level of adiponectin

is protective against incident myocardial infarc-

tion (MI), even after correcting for cholesterol

levels. This produced up to a 40 percent MI risk

reduction in the Healthcare Professionals Fol-

low-up Study, said Lam. In obese individuals

who did not undergo bariatric surgery, a follow-

up of 10 years found that a protective effect for

the development of T2DM and MI was conferred

by adiponectin. This was confirmed by a 16-year

longitudinal study in the CRISPS cohort in which

the ADIPOQ gene +276G>T (rs1501299) SNP

when present even in the heterozygous state,

was associated with an increased risk of coro-

nary heart disease in men even after correcting

for confounding risk factors, she added.

In diabetic nephropathy, serum adiponectin

is inversely related to albumin excretion rates

in individuals with normal albuminuria. How-

ever, once the state of microalbuminuria or al-

buminuria is reached, the direction of the rela-

tionship is changed, with a positive correlation

observed between serum adiponectin and uri-

nary albumin concentration (UAC). An inverse

The myriad of studies described

show clear potential for themanipulation of adiponectin

in diseased states to create

therapeutic remedies


28/33


relationship is also observed between serum

adiponectin levels and glomerular filtration rate

(GFR). However, patients with end-stage renal

failure have serum adiponectin levels as high

as controls, potentially as a result of a second-

ary phenomenon. [Kidney Int 2013;83:487-494;

Nephrol Dial Transplant 2014;doi:10.1093/ndt/

gfu249] These indicate that levels of serum adi-

ponectin differ according to phases of nephrop-

athy. In a prospective study of a small cohort

with relatively well preserved kidney function

followed up to 20 months, a low serum adipo-

nectin level was able to predict progression of

albuminuria, suggesting that in this selected

population, adiponectin is indeed protective

against renal failure, said Lam.

Fatty liver disease is another complication fre-

quently seen among T2DM patients. An inverse

relationship is seen between serum adiponec-

tin and serum alanine aminotransferase (ALT),

suggesting a protective effect conferred by the

protein. The increase in serum adiponectin lev-

els also correlates to improvements in hepatic

incidences. [J Clin Invest2003;112:91-100]

It is now commonly known that T2DM in-

creases the risk for the development of certain

types of cancers. These include cancer of the

pancreas, liver, colorectum, bladder and repro-

ductive tract. Adiponectin, working through vari-

ous signaling mechanisms, has been shown to

decrease cell proliferation in many animal- and

cell-based studies. In humans, low adiponectin

levels found in diabetes-related cancer patients

have been found to have a decreased ability to

limit proliferation and metastasis. [Endocr Relat

Cancer 2009;16:1103-1123; Diabetes Care

2010;33:1674-1685]

The myriad of studies described show clear

potential for the manipulation of adiponectin in

diseased states to create therapeutic remedies.

Current anti-diabetic and cardiovascular drugs

such as agonists of peroxisome proliferator-

activated receptor (PPAR) and statins are as-

sociated with increased plasma adiponectin in

humans. The recently discovered fibroblast

growth factor 21 (FGF21), a metabolic regula-

tor, is the most potent adiponectin stimulator to

date, said Lam. Many pharmaceutical com-

panies are now developing FGF21 mimetics

or analogues to improve the activity as well as

the circulating half-life of FGF21. All these are in

various stages of clinical trials, one of which has

already been used in a phase II clinical trial in

humans, she added.

Lam also briefly spoke of the importance

of lifestyle measures in improving adiponectin

levels, stating that a low-energy Mediterranean

diet, combined with increased physical activ-

ity, has shown to increase adiponectin levels by

30 percent over 2 years in individuals who suc-

ceeded in losing weight. [JAMA2003; 289:1799-

1804]


29/33


DR. JOSLYN NGU

Metformin is commonly used to treat type 2diabetes mellitus (T2DM), but it may haveother benefits, says a prominent specialist.

In recent years, metformin has been suggest-

ed to have beneficial effects in type 1 diabetes

mellitus (T1DM), heart failure (HF) and cancer,

said Professor Andrew Morris, vice principal,

data science, School of Molecular, Genetic and

Population Health Sciences, University of Edin-

burgh, UK.

A systemic review of 197 clinical trials showed

that prescribing metformin on top of insulin ther-

apy to patients with T1DM reduces insulin-dose

requirement. Metformin was also linked to reduc-

tions in HbA1c, weight and total cholesterol. Still,

it is not conclusive whether these benefits last

more than a year and if there is any additional car-

dioprotective benefit. [Diabetologia2010;53:809-

820]

Currently, there are 24 clinical trials investigat-

ing the effects of metformin on HF, said Morris.

Examples of older studies that have demonstrat-

ed the cardioprotective benefit of metformin are,

for one, a Canadian study that ran from 1991 to

1996. The study analyzed the data of patients re-

ceiving oral anti-diabetic therapies from the Sas-

katchewan Health database. The researchers

found that metformin monotherapy or in com-

bination with sulfonylurea were associated with

improved mortality rates in patients with diabetes

and HF compared with sulfonylurea monothera-

py alone. [Diabetes Care 2005;28:2345-2351]

Another study alluding to metformins cardio-

protective benefit utilized information from the

Diabetes Audit and Research in Tayside Scot-

land (DARTS) database. The study included

diabetic patients who had a history of conges-

tive heart failure (CHF) and were prescribed oral

antidiabetic agents, but not insulin. The findings

concluded that metformin may lower the risk of

death in patients with CHF and DM when used

as monotherapy or in combination with sulfonyl-

urea. [Am J Cardio2010;106:1006-1010]

There is also the link between metformin and

cancer to be explored further. Metformin activates

AMP-activated protein kinase (AMPK) in hepato-

cytes, which leads to reduced hepatic glucose

production and increased glucose utilization. An-

drew said there is new insight into the function

of AMPK. As LKB1 is an upstream regulator of

AMPK and a known tumor suppressor, metformin

may be able to lower cell turnover and protein

synthesis. [J Biol2003;2:28] He said that based

on data from clinicaltrials.gov, there are currently

214 studies on metformin and cancer patients.

As Morris said, We are only at the beginning.

As the understanding of how metformin works

improves, so will the quality of treatment.

Diabetes Asia 2014 Conference, October 16-19, Kuala Lumpur, Malaysia

Possible future indications

for metformin


30/33

DECEMBER 2014 CALENDAR 30

DECEMBER

20th World Congress onControversies in Obstetrics,Gynaecology and Infertility (COGI)

4/12/2014 to 7/12/2014Location: Paris, FranceInfo: COGI SecretariatTel: (972) 73 706 6950Fax: (972) 3 725 6266Email: [email protected]: www.congressmed.com/cogi

12th Asian Congress of Urology(ACU)

5/12/2014 to 9/12/2014Location: Kish Island, IranInfo: Secretariat

Tel: (971) 4 4218996Fax: (971) 4 4218838Email: [email protected]: http://12thacu2014.org

56th American Society ofHematology Annual Meeting andExposition (ASH)

6/12/2014 to 9/12/2014Location: San Francisco, USInfo: ASH Registration CenterTel: (1) 888-273-5704 - US andCanada

Tel: (1) 703-449-6418 - InternationalFax: (1) 703-563-2715Email: [email protected]: www.hematology.org

37th San Antonio Breast CancerSymposium (SABCS)

9/12/2014 to 13/12/2014Location: San Antonio, Texas, USInfo: SABCS RegistrationTel: (1) 210-450-1550Fax: (1) 210-450-1560Email: [email protected]

Website: www.sabcs.org

UPCOMING

International Conference onInfectious and Tropical Diseases

16/1/2015 to 18/1/2015

Phnom Penh, CambodiaInfo: Govt. Gandhi Memorial ScienceCollegeEmail: [email protected]: http://10times.com/ictid

9th Asia Pacific Conference onClinical Nutrition (APCCN)

26/1/2015 to 29/1/2015Location: Kuala Lumpur, MalaysiaInfo: Congress SecretariatTel: (603) 2162 0566Fax: (603) 2161 6560

Email: [email protected]: www.apccn2015.org.my

14th World Congress on PublicHealth

11/2/2015 to 15/2/2015Kolkata, IndiaPhone: (91) 124 463 6713Email: [email protected]: www.14wcph.org

24th Conference of the AsianPacific Association for the Study of

the Liver (APASL)12/3/2015 to 15/3/2015Location: Istanbul, TurkeyInfo: APASL SecretariatTel: (90) 312 440 50 11Fax: (90) 312 441 45 63Email: [email protected]: www.apasl2015.org

World Congress of Nephrology(WCN) 2015

13/3/2015 to 17/3/2015Location: Cape Town, South

AfricaInfo: International Society ofNephrologyTel: (32) 2 808 71 81Fax: (32) 2 808 4454Email: [email protected]: www.wcn2015.org

64th Annual Scientific Session ofthe American College of Cardiology(ACC)

14/3/2015 to 16/3/2015Location: San Diego, California, US

Info: ACC Registration and HousingCenterTel: (1) 703 449 6418Email: [email protected]: http://accscientificsession.cardiosource.org/ACC.aspx

6th Association of Southeast AsianPain Societies (ASEAPS) Congress

15/3/2015 to 17/3/2015Location: Manila, PhilippinesInfo: ASEAPS SecretariatTel: (65) 6292 0732

Fax: (65) 6292 4721Email: [email protected]: www.aseaps2015.org

16th World Congress on HumanReproduction

18/3/2015 to 21/3/2015Location: Berlin, GermanyInfo: Biomedical Technologies srlTel: (39) 070340293Fax: (39) 070307727Email: [email protected]: www.humanrep2015.com

4th Global Congress for Consensusin Pediatrics and Child Health (CIP)

19/3/2015 to 22/3/2015Location: Marrakech, MoroccoInfo: Paragon GroupTel: (41) 22 5330948Fax: (41) 22 5802953Email: [email protected]: http://2015.cipediatrics.org/marrakesh/

World Congress on Osteoporosis,

Osteoarthritis and MusculoskeletalDiseases (WCO-IOF)

26/3/2015 to 29/3/2015Location: Milan, ItalyInfo: Yolande Piette CommunicationTel: (32) 0 4 254 1225Fax: (32) 0 4 254 1290Email: [email protected]: www.wco-iof-esceo.org


31/33

DECEMBER 2014 HUMOR 31

Forget about organic food.At your age, you need all the

preservatives you can get!

What do you meanyou feel dehydrated?

I had a great evening and Iwould love to ask you in, but I

heard you doctors dont makehouse calls!

Its about time you showed up!When did you discover thatyou were accident prone?

I dont think doctors are ready for,

what you call, post impressionism X-rays!

Shall we begin?


32/33

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Go towww.mims.asia/video

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interviews with leading experts

Find out what these experts have to say about how to improve

patient care for osteoporosis and sarcopenia in Asia through

awareness building and the use of new therapies

_series Brought to you by MIMS

SCAN TO WATCH VIDEO

ProfessorPeter Ebeling

Widespread vitamin D

deficiency and low calcium

levels in Asians

How low levels of awareness

in the public and in

healthcare professionals

affect osteoporosis care in

Asia

Benefits of fracture

registries and fracture liaisonregistries (FLS) in Asia

ProfessorSerge Ferrari

Selective estrogen

receptor modulators

(SERMs), a new class of

therapy for post-menopausal

woman with osteoporosis

Dr Edith Lau

Treatment plans for

post-menopausal women

with osteoporosis

Professor BessDawson-Hughes

How aging contributes to

sarcopenia and impaired

muscle function in the

elderly


33/33

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