Medical Tribune May 2013

7/30/2019 Medical Tribune May 2013

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May 2013

www.medicaltribune.com

HPS2-THRIVE trial:

Negave results for

niacin

Low melatonin

secreon linked to

diabetes risk

NEWS

Managing wrist pain

IN PRACTICE

CONFERENCE

AFTER HOURS

Geng around on the

London Underground

Diabetes research failing to address

prevention


2/39

2 May 2013

Diabetes research failing to address

prevention

Laura Dobberstein

The prevention of diabetes is being over-looked by diabetes researchers, accord-ing to a recent study.

Our descriptive analysis found that themajority of registered [diabetes] trials involvedrug therapies rather than preventative or

non-drug interventions, said study authorDr. Jennifer Green of Duke University Medi-cal Center in Durham, North Carolina, US,and colleagues.

Green and her team examined 2,484 in-terventional diabetes trials registered on theClinicalTrials.gov website between 2007 and2010, to beer understand which aspects ofthe disease were being addressed. [Diabetolo-

gia 2013; doi:10.1007/s00125-013-2890-4]

While 75 percent of the trials had a pri-marily therapeutic purpose, only 10 percentfocused on prevention. Sixty-three percent ofinterventions used drugs and only 12 percentlooked at modiable behaviors.

Their ndings also indicated some impor-tant demographic disparities of trials, whichtended to exclude children and the elderly,were oen small in size and duration, did

not geographically represent populations ofthose living with diabetes, and did not focuson signicant cardiovascular outcomes likeheart aack and stroke.

Twenty percent of adults over age 65 havediabetes, but less than 1 percent of the tri-als included patients in this age group. Mosttrials excluded patients over 75 years of ageand 30.8 percent excluded those over the ageof 65.

Four percent of trials targeted those un-der the age of 18. This low number of pedi-

atric trials may accurately reect the propor-tion of people in this age group aected bydiabetes. However, arguments exist as to whythis group should be beer represented inresearch. A 3 percent annual increase in type1 diabetes currently exists among those un-der the age of 18. In addition, children havea higher chance of developing complicationsduring their disease course and benet morefrom beer disease management than theirolder counterparts.

The small size and duration of the trialsconcerned the researchers. The average lengthof a trial was less than 2 years. Over half of alltrials had fewer than 100 participants and 91percent had fewer than 500 participants.

Complications like diabetic retinopathy,lower extremity amputation and end-stage re-

nal disease vary among ethnic groups, makingit important to include a diverse backgroundof people in diabetes research. Study popula-tions were overrepresented by patients fromNorth America, Western Europe and certainAsian countries, but underrepresented by pa-tients from other important regions such asRussia, Brazil and the Middle East.

Cardiovascular complications related to

diabetes have become an important researchtopic, particularly in relation to medicationdevelopment. Yet mortality and cardiovascu-lar complications were only reported in 1.4percent of trials.

The researchers concluded that currentclinical trials on diabetes research do not ade-quately address disease prevention, manage-ment or therapeutic safety. The results fromthis study build a beer understanding of on-

going research and could help direct futureresearch activities and resources.


3/39

3 May 2013

Fast foods going cardio smart

Naomi Rodrig

Public education eorts promoting

healthy lifestyle for the prevention of

cardiovascular disease seem to be bear-

ing fruit as some fast food chains are moving

towards healthier menu options.

At the recent American College of Cardiol-

ogy (ACC) Annual Scientic Sessions in San

Francisco, California, US, Subway was pro-

moting heart-healthy meals, with detailed

nutritional information about its sandwich

and beverage choices. Subway was the rst

fast food chain to receive the American Heart

Associations (AHA) Heart Check certica-

tion by meeting AHAs criteria. Heart Check

meals contain


4/39

4 May 2013 Forum

Conqering cardiovasclar disease

arond the globe

Excerpted from a keynote lecture by Dr. William Zoghbi, president of the American College

of Cardiology (ACC), during the 62nd Annual Scientic Sessions of the ACC, held recently in

San Francisco, California, US.

W

hen we think about overall cardio-

vascular care, we need to consider

all the elements. Certainly, rst

and foremost is the care of the patient with

heart disease. Of course there are many other

factors that we must consider and dedicate

our eorts to, starting with early detection of

disease, raising awareness about the impact

of obesity, inculcating healthy behaviors and

considering the contributions of genetic fac-

tors and, importantly, ethnic backgrounds.

We aim for beer care, beer population

health and aordable care from the perspec-

tive of both the patient and society.

The ACCs answer to achieving this triple

aim has emphasized quality, value and pro-

fessionalism. The college has also focused on

patient-centered care and is seeking collabo-

rations among organizations for the develop-

ment of guidelines, quality tools and health

policies.Key ACC initiatives to help advance car-

diovascular health include data registries and

their impact, appropriate use of diagnostic

modalities and interventions, strategies to

empower patients with knowledge, and ap-

proaches to deal with public health challeng-

es, both locally and globally.

National data registries provide important

data on practice of medicine and patient out-comes. The ACCs National Cardiovascular

Data Registry, or NCDR, celebrates its 15thyear this year and it has become the ag-

ship of registries, growing to a total of seven

registries. These cover most areas of cardiol-

ogy, including interventional cardiology, im-

plantable cardioverter debrillator therapy,

management of acute myocardial infarction,

congenital heart disease and, most recently,

transcatheter valve therapy. These continual-

ly enrolling registries have more than 24 mil-lion records.


5/39

5 May 2013 Forum

What is also exciting is that some of these

registries have gone global, with presence in

Asia, the Middle East and South America.

This enables sharing and comparing of car-

diovascular care quality between nationsworldwide with the goal of improving car-

diovascular care.

Our most recent partnership with the So-

ciety for Thoracic Surgery, as well as regula-

tory agencies, payers and industry, ushers in a

new registry paradigm this one for patients

with advanced aortic stenosis mandating

participation for reimbursement while moni-

toring quality, patient outcome and support-

ing research and innovation.

The power of data reporting can change

clinical practice and improve quality of care.

Before reporting door-to-balloon data for

treatment of acute heart aack, most hospi-

tals and physicians believed they were do-

ing a great job in this type of care. With the

data, the percent of patients achieving a door-

to-balloon time of less than 90 minutes im-

proved. Such data also lowered the rate of in-

appropriate angioplasties in favor of medical

treatment.

Reecting on the application of knowledge,

while science tells us what we can do, guide-

lines tell us what we should do, and registries

show us what we are actually doing and will

likely be doing in the future.A key component of high-quality care plac-

es an emphasis on the patient. This is where

we need to be spreading the word about

healthy living and healthy choices in the com-

munity.

On one hand, looking back on the impact of

cardiovascular interventions and outcomes, it

is really gratifying to see the signicant de-

cline in cardiovascular mortality in the USover the past 40 years, thanks to advances in

research, medications, devices and catheter-

based and surgical interventions.

However, many challenges remain. In the

US, many patients who need to take aspirin

are not. And many are in need of beer bloodpressure control and cholesterol manage-

ment. Smoking rates, although beer than in

other countries, are still far from optimal.

Even more urgent are challenges looming

globally. Death from cardiovascular disease

exceeds that from any other disease and ac-

counts for about one-third of total deaths

worldwide. It is higher than cancer, respira-

tory disease and diabetes, the other main non-

communicable diseases (NCDs), combined.

The projected trends are alarming as they

gradually increase for both cardiovascular

disease and cancer.

There are 10 highest risk factors for cause of

total death worldwide. The most important is

high blood pressure followed by tobacco use,

high glucose, physical inactivity, overweight

and obesity, and high cholesterol. Many of

these risk factors are the same for other NCDs.

Therefore, addressing them will have a major

impact on global health, not only cardiovas-

cular health.

Prompted by the NCD Alliance, the United

Nations had its rst ever high-level meeting

on NCDs in September 2011. The outcome of

the summit was a political declaration thatcalled on the World Health Organization to

establish global targets for curbing NCDs. In-

deed, the World Health Assembly met in Ge-

neva in May 2012 and approved a monumen-

tal goal: a 25 percent reduction in premature

mortality from NCDs by the year 2025.

To achieve that overall goal, the following

targets were adopted: reductions in tobacco

smoking, physical inactivity, excessive alco-hol use, salt intake, raised blood pressure,


6/39

6 May 2013 Forum

diabetes and obesity. Availability of essen-

tial medications to prevent heart aack and

stroke was also emphasized.

Going forward, there are challenges but

great opportunities to reach this ultimategoal. As risk factors are so prevalent and tra-

ditional treatments are aordable, there is no

need for new inventions globally.

A big challenge is implementing the reso-

lutions of various targets, knowing these may

vary by nation. It is crucial to establish beer

funding for the NCD movement currently

NCDs cause about 60 percent of global deaths

yet receive about one percent of health fund-

ing. So the time is now for us to act and work

collaboratively.Cardiovascular disease is a global prob-

lem. We can protect population health by

taking a global perspective and working to-

gether with ACC chapters and national and

international organizations to reach this no-

ble goal.


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7 May 2013 Conference Coverage

Preventing cardiovasclar disease: Do thevery elderly reqire a different approach?

62nd Annual Scientifc Sessions o the American College o Cardiology, 9-11 March, San Francisco,

Caliornia, US

Excerpted from a lecture by Dr. Janice Schwartz, clinical professor of Medicine, Bioengineering,

and Therapeutic Science at the University of California, San Francisco, US, during the 62nd

Annual Scientic Sessions of the American College of Cardiology, held recently in San

Francisco, California, US.

When I rst thought about whether

the very elderly require a dier-

ent treatment approach, I said yes.

Its obvious, there is no question we should

be treating elderly patients dierently than

younger patients.

I think the individual treatment goals

might dier as you have older patients. They

certainly have more comorbidities and those

are going to inuence our choices and limit

our options. And clearly cost limits the op-

tions elderly women in the US have the

highest level of poverty of any group. But if

the goal is the best therapy for each patient,

then we have the same goal for all patients.

However, maybe the approach should be

to choose options and therapy that benet thepatient in their life span. Im going to dene

benet as meeting the goals of the patient and

improving the function or quality of life that

is a wonderful goal and cardiologists are com-

ing around to that. We no longer look at just

prolongation of life as a good outcome, were

willing to say fewer hospitalizations and de-

creases of morbidity are a valid goal.

Im also going to introduce the conceptthat we would like to prevent decline in de-

pendency. If you ask your patients and give

them informed consent before procedures,they might tell you they dont mind dying but

Regular activity in the very elderly improves quality of life andlife expectancy.


8/39


they dont want to wake up with a stroke and

be dependent.

Consider life expectancy over patient age

When we think about diseases and risk fac-tors, we really have a goal of treatment, and

we can do it in the middle-aged and younger

patients. The goal is prolonging their life.

But as people get older, the things that be-

come important are quality of life and mainte-

nance of function. The challenge is, of course,

when were going to start shiing from think-

ing about life prolongation to quality of life

and function.

The key concepts that provide a framework

for decision making are to estimate life expec-

tancy in the elderly and very elderly, recog-

nize the importance of function and the lag-

time until benet or harm of therapies, and

patient-centered decisions.

Data from the US Census Bureau show

that an 85-year-old man might have on aver-

age 5.7 years to live, a 90-year-old has another

4 years to live and if you make it to 100 you

will probably live another 2 years, on aver-

age. For women those years are even longer.

The 85-year-old might be living out to about

7 years, the 90-year-old has another ve years

and the 100-year-old is going to have about

2.3 years.

But thats average life span and, as the

economist Milton Friedman said: Never try

to walk across a river just because it has anaverage depth of four feet.

In an average life span for people between

70-90 years, there is considerable variability.

So I think we have to do a beer job when we

come to individual decisions about our pa-

tients to try and project their life span.Traditional risk calculators such as the

Framingham risk score and the Reynolds risk

score do not help decision making for the el-

derly.

Risk factors that are important in the older

group are age, sex, body mass index, the pres-

ence of chronic diseases, smoking, diculty

with the activities of daily living, managing

nances, the ability to walk several blocks,

and trouble pushing large objects.

Prognosis calculators that weigh these in-

dicators for the elderly might show that the

odds of dying within 4 years for someone

who does not have diabetes or is overweight

and doesnt have cancer or smoke but has dif-

culty bathing or with other activities of daily

living might be 59 percent. However, the ad-

dition of congestive heart failure to a person

with this prole would only increase the odds

of dying within 4 years to 64 percent.

The things that drive life expectancy in this

group are really the activities of daily living

bathing, dressing, managing nances, and so

on certainly much more so than heart failure.

Similar risk calculators for this group in-

clude determining whether patients havebeen hospitalized, if they can read a news-

paper, do they have hearing impairment or

weight loss, are they receiving home care ser-

vices and whether they are poor.

So if the risk factors are dierent, should

treatment be dierent?

Treat with life span in mind

As an example, one trial compared statintherapy with placebo in 5,804 patients aged

The challenge is, of course,

when were going to start shiing

from thinking about life prolongation

to quality of life and function


9/39


70-82 years over 4 years with a history or risk

of vascular disease. [Lancet 2002;360:1623-

1630] Even by the time one begins to see ben-

ets from the statin, the risk of death or car-

diovascular events remains almost the same,and certainly up to 2 years. So I would say

someone with a life expectancy less than 2

years is not going to benet and therapy may

well hurt them, it will certainly cost more.

If we also look at the evidence for aspirin

for primary prevention, we see aspirin re-

duces the risk of myocardial ischemic events,

with a higher rate of bleeding, according to

one study, and does not prolong life. Again,

the treated time-to-benet is not until 3.7-10

years out. [Lancet 2009;373:1849-1860]

Here patients may not live that long so

they dont get the potential benet, there is

no dierence in cardiovascular mortality but

bleeds happen earlier and they risk hemor-

rhagic stroke.

The American Geriatric Society says yes,

the elderly require dierent approaches, for

example, when picking medications for hy-

pertension, using aspirin for primary pre-

vention of cardiac events, using potentially

inappropriate drugs with caution and advise

against tight glucose control, calling moder-

ate control beer.

Make exercise a priority

The one thing that helps everything a pa-

tient has is exercise. We should be the leaders

in developing exercise programs that are go-

ing to benet the whole patient, especially theolder patient. It doesnt need to be intense ex-

ercise like it should be for cardiovascular ben-

et in middle-aged men. There are no short-

term adverse eects, there is a short lag-time

for benet and the benets hit the body both

above and below the waist.

The US National Institutes of Health says

regular activity improves quality of life, ex-

tends life and decreases the risk of cardiovas-

cular disease and other illnesses and disabili-

ties.

To conclude, they key considerations for

the very elderly are estimated life expectancy

not age alone lag-time to potential benet

and adverse treatment eects and burden.

Estimates of benets and harms should be

weighted with qualitative judgments of indi-

viduals values and preferences. Function and

not cardiovascular risk factors have the great-

est impact on life expectancy and quality of

life in the very old. And we must focus on im-

proving function with exercise and prevent-

ing the conditions that decrease function and

quality of life.


10/39


Cangrelor otperforms clopidogrel

dring PCI


Caliornia, US

Elvira Manzano

T

he new anti-cloing agent cangrelor,

given during percutaneous coronary

intervention (PCI), performed beer

than mainstay drug clopidogrel at reducingischemic events, according to results from the

CHAMPION PHOENIX* trial.

Cangrelor signicantly reduced the pri-

mary endpoint of composite rate of death,

myocardial infarction (MI), ischemia-driven

revascularization and stent thrombosis by

22 percent at 48 hours post-randomization

(p=0.005) without an increased risk of severe

bleeding (p=0.44). This benet was drivenby a 20 percent reduction in the rate of acute

MI and a 38 percent reduction in the inci-

dence of stent thrombosis. [N Engl J Med 2013;

doi:10.1056/NEJMoa1300815]

Cangrelor may be an aractive option

across the full spectrum of patients undergo-

ing PCI, said rst study author Dr. Deepak L.

Bha from the VA Boston Healthcare System

and Brigham and Womens Hospital in Bos-ton, Massachuses, US. Unlike clopidogrel,

cangrelor takes eect rapidly and wears o

within an hour of infusion, which allows for

exibility to initiate and stop ADP inhibition

immediately in patients requiring urgent sur-

gery or in those who develop bleeding com-

plications, Bha added.

Despite being a more potent antithrom-

botic than the comparator, there was no bad

bleeding that would be worrisome when add-

ing another drug into the medical regimen,

said Dr. Robert Harrington of Stanford Uni-

versity School of Medicine in California, US,

and co-principal investigator of CHAMPION

PHOENIX.

CHAMPION PHOENIX is a randomized,

double-blind, all-comer trial involving11,145 patients with acute coronary syndrome

(stable angina, non-STEMI or STEMI) or other

conditions requiring urgent or elective PCI,

randomized to a bolus and infusion of can-

grelor or a loading dose of oral clopidogrel

(600 mg or 300 mg).

Overall, procedural complications were

less common with cangrelor (3.4 percent vs

4.5 percent; p=0.002) as well as the need for

rescue therapy with glycoprotein IIb/IIIa in-

Cangrelor successfully reduced ischemic events without increased risk ofsevere bleeding, but it wont be routine therapy for all PCI patients yet.


11/39


hibitors (p


12/39


HPS2-THRIVE randomized 25,673 high-

risk heart patients from Europe and China to

a combination of ER niacin/laropiprant or a

placebo. All patients received standard low-

density lipoprotein (LDL) lowering therapyconsisting of simvastatin with or without

ezetimibe.

The most striking aspect of the trial was the

excess of serious adverse events as a result of

niacin therapyevents signicant enough to

result in hospitalization or signicant illness,

which went beyond the well- known side ef-

fects of niacin.

Over the course of the 3.9-year study, there

were 31 serious adverse events per 1,000 nia-

cin-treated patients.

Compared with placebo, niacin resulted in

an excess of 3.7 percent diabetic complications,

1.8 percent new-onset diabetes, 1.4 percent in-

fections, and 1 percent gastrointestinal adverse

events (p


13/39


Long-term otcomes of TAVR, srgery

similar in severe aortic stenosis


Caliornia, US

Elvira Manzano

Transcatheter aortic valve replacement(TAVR) remains comparable to openheart surgery in the long term in pa-

tients with severe aortic stenosis at high riskfor surgery, according to the updated resultsof the PARTNER* trial, but mortality rateswith both approaches are high.

At 3 years, there was no statistical dierencein the primary endpoint of all-cause mortality

between the two groups 44.2 percent withTAVR and 44.8 percent with open heart surgery.Stroke rates were also no dierent at 8.2 percentand 9.3 percent, respectively. Paravalvular leaks

or regurgitation were persistent and fatal.TAVR should be considered an alternative

to surgery with similar mortality and othermajor clinical outcomes, said study present-er Dr. Vinod Thourani from Emory Univer-sity School of Medicine in Atlanta, Georgia,US. Future eorts should be directed towardreducing TAVR-procedure-related complica-tions, including strokes, vascular events and

paravalvular regurgitation.One-year results from the PARTNER A

trial, presented 2 years ago, showed similarmortality outcomes for TAVR and surgery.However, strokes and transient ischemic at-

tacks (TIA) were signicantly higher withTAVR. The trial was extended to assess long-term outcomes and valve performance. At 2years, even mild paravalvular regurgitationwas associated with increased mortality.

PARTNER A included 699 patients (medi-an age, 84.1) enrolled between May 2007 and

September 2009 and randomized to catheter-based procedure either through transapicalor transfemoral access or surgery. At 3 years,there were more major vascular complica-tions with TAVR (12.5 percent vs 3.8 percent;p


14/39


On- vs off-pmp CABG: Patient factors,

srgical expertise are ey


Caliornia, US

Dierent types of CABG surgery continue to show mixed outcomeresults.

Naomi Rodrig

T

hree late-breaking clinical trials com-

pared on-pump versus o-pump coro-

nary artery bypass gra (CABG) sur-

gery, reporting mixed outcomes, according tostudy population.

On-pump CABG is less demanding surgi-

cally but more expensive, requiring a heart-

lung machine and disposable components.

Conversely, the less costly o-pump or beat-

ing-heart procedure requires a higher degree

of surgical expertise. Previous trials compar-

ing the two techniques reported conicting

results, and o-pump procedures have be-come less popular during the past decade, es-

pecially in developed countries.

The German O-Pump CABG in Elderly

Patients (GOPCABE) study randomized 2,539

patients aged 75 years undergoing elective,

rst-time CABG to on- or o-pump surgery.

There was no signicant dierence in the

primary composite endpoint of death, stroke,

myocardial infarction (MI), repeat revascu-larization or new renal replacement therapy

within 30 days of surgery between the two

arms [8.2 vs 7.8 percent; p=0.74], reported

Dr. Anno Diegeler of the Heart Center Bad

Neustadt, Bad Neustadt, Germany. Results

for all components of the primary endpoint

were similar between the groups at 30 days,

and there was also no signicant dierence in

the rate of the primary endpoint at 12 months

(14.0 vs 13.1 percent; p=0.483).

Our data showed that CABG can be per-

formed in the elderly population with excel-

lent results, and this is equally true for bothtechniques. The less costly o-pump surgery

may be benecial in developing countries,

he said.

CORONARY the largest trial to compare

the two procedures examined the composite

of death, stroke, MI or new kidney failure in

4,752 patients scheduled to undergo CABG.

As reported previously, there was no dier-

ence between patients receiving the o-pump

and on-pump surgery at 30 days (12.2 vs 13.3


15/39


percent; p=0.24). We now found that both

on-pump and o-pump bypass have similar

results even at 1 year, said lead investigator

Dr. Andre Lamy of McMaster University in

Ontario, Canada. The rates of coronary re-vascularization were also similar between the

groups.

While neurocognitive decline might be

more prominent with on-pump surgery, the

researchers found only a transient improve-

ment in neurocognitive function among those

receiving o-pump CABG. At 1 year, our

results were similar with both techniques, as

was quality of life, he said.

In contrast, the single-center PRAGUE-6

trial, which randomized 206 high-risk pa-

tients (EuroSCORE 6) to receive on- or o-

pump CABG, found a signicantly lower rate

of the primary endpoint among patients re-

ceiving the o-pump procedure (9.2 vs 20.6

percent; p=0.028). Furthermore, a signicant-

ly higher percentage of on-pump patients re-

quired a blood transfusion (80.2 vs 64.9 per-cent; p=0.017).

Our study shows that surgical revascular-

ization without using the heart-lung machine

can be benecial for high-risk patients, espe-

cially older ones with many other disorders

or diseases, concluded Dr. Jan Hlavicka, of

Charles University in Prague, Czech Republic.

All investigators stressed that risk assess-

ment and surgical expertise are key factors

aecting patient outcomes. Therefore, sur-

geons should tailor their surgical approach to

their technical expertise and expected techni-

cal diculty, suggested Lamy.


16/39


17/39

17 May 2013 News

Srgery tops medical therapy for obese

diabetics

Bariatric surgery is a treatment option to beer manage obese diabetics.

Elvira Manzano

Bariatric surgery improved glycemic

control beer than optimal medical

therapy alone in obese patients with

type 2 diabetes independent of weight loss,

two randomized trials have shown.

In the larger of two trials (STAMPEDE*),

HbA1c levels normalized to 6 percent by 1

year, the primary endpoint, in 42 percent and

37 percent of patients who underwent gastric

bypass and sleeve gastrectomy, respective-

ly, compared with 12 percent in those who

received intensive medical therapy alone

(p=0.002 and p=0.008).

Average weight loss was greater aer surgi-

cal procedures than aer medical therapy (60

lbs vs 10 lbs). Medication use to control lip-

ids, glucose and blood pressure also dropped

signicantly aer surgical procedures, but in-

creased with medical therapy alone. [N Engl J

Med 2012;366:1567-1576]

STAMPEDE included 150 obese patients

(BMI, 27-43 kg/m2) with uncontrolled type 2

diabetes randomized to Roux-en-Y surgery or

sleeve gastrectomy, or medical therapy alone.All patients received intensive medical thera-

py (lifestyle counseling, weight management,

glucose monitoring and newer diabetes drugs)

prior to randomization. BMI, body weight and

insulin resistance improved signicantly in

those who underwent bariatric surgery.

The take home message is that surgical

patients enjoyed not only signicant or supe-

rior improvement in glycemic control but didso on much lower regimens of diabetic and

cardiovascular medications, said STAM-

PEDE study author Dr. Philip R. Schauer from

Cleveland Clinic, Ohio, US.

In a second trial, bariatric surgery resulted

in greater reductions in fasting glucose and

HbA1c levels aer 2 years than did medical

therapy. Seventy-ve percent of patients on

gastric-bypass and 95 percent on biliopan-

creatic-diversion (p


18/39

18 May 2013 News

conventional medical therapy (medication,

strict diet and lifestyle interventions), or gas-

tric bypass surgery or biliopancreatic diver-

sion.

Both studies targeted an HbA1c level of


19/39

19 May 2013 News

Radha Chitale

Women who produce low levels of

nocturnal melatonin are more than

twice as likely to develop type 2

diabetes independent of other major diabetes

risk factors, according to a recent observation-

al study.

The case-controlled study drew data from

a cohort in the US Nurses Health Study and

included women who provided urine and

blood samples at baseline in 2000. Over 12

years, 370 women developed type 2 diabetes

and the researchers matched these subjects

with an equal number of controls. [JAMA

2013;309:1388-1396]

The researchers measured melatonin se-

cretions indirectly using creatinine as a proxy

marker. The median urinary melatonin-to-

creatinine ratio among controls was 36.3 ng/

mg, which was higher than the median ratio

of the diabetic group (28.2 ng/mg).

Women in the diabetes group were divided

into three groups of low, medium and high

melatonin secretors. The median urinary mel-

atonin-to-creatinine ratio was 67 ng/mg amonghigh melatonin secretors compared with 14.4

ng/mg among the low-secretion group.

Women with low levels of nocturnal mela-

tonin were 2.2 times more likely than high

melatonin-secreting women to develop type 2

diabetes. The researchers controlled for body

mass index, lifestyle and location factors,

menopause, history of diabetes, hypertension,

use of beta blockers or non-steroidal anti-in-ammatory drugs and diabetes biomarkers.

Lead researcher Dr. Ciaran J. McMullan of

Brigham and Womens Hospital, Boston, Mas-

sachuses, US, said the results translated to

9.3 cases of diabetes per 1,000 patient-years

among low-secreting women compared with

4.3 cases among high-secreting women.

Normally, melatonin levels tend to be low

throughout the day, rise in the evening, pla-

teau while sleeping and drop upon waking.

Prior studies have shown that insulin resis-

tance and type 2 diabetes is associated with loss-

of-function mutations in melatonin receptors.

McMullan said the data suggests that en-

dogenous levels of melatonin may be part

of the pathogenesis of diabetes, however the

wide variation in melatonin secretion levelsmakes unraveling the connection dicult.

The question remains as to whether mela-

tonin could be a modiable risk factor for the

prevention or possibly treatment of type 2 di-

abetes, endogenously through dark exposure

or exogenously through oral supplements,

the researchers noted.

Further studies on dierent populations,

including men and other ethnic groups, mayalso be indicated.

Lo melatonin secretion lined to

diabetes ris

Melatonin may play a role in the pathogenesis of type 2 diabetes.


20/39

20 May 2013 News

Telehealth not cost-effective, stdy shos

Radha Chitale

Telehealth may not be the cost-saving

model of care its been touted as, a new

study from the UK shows.

Quality of life was no dierent for chroni-

cally ill patients who tacked telehealth mea-

sures onto their standard supportive care

compared with similar patients who received

usual care.

Telehealth encompassed digital telemoni-

toring of patient vital signs, in real time or

saved for later access, as well as telephone

support, during which healthcare profession-

als could also monitor and track vitals, and

added to the overall costs for patients that re-

ceived it.

The QALY [cost per quality adjusted life

year] gain by patients using telehealth in ad-

dition to usual care was similar to that by

patients receiving usual care only, and total

costs associated with the telehealth interven-

tion were higher, the researchers said.

A group of 965 patients from a larger tele-

health trial were eligible for inclusion in this

questionnaire study on health outcomes.

These patients had to have at least one of

three chronic diseases: chronic obstructivepulmonary disease, heart failure or diabetes.

[BMJ2013;346:f1035]

Patients were randomized to telehealth in-

tervention (n=534) or to usual care (n=431).

QALY for telehealth plus usual care was

92,000 (S$174,000), which is well above the

UK National Institute for Health and Clinical

Excellence threshold of 30,000 (S$57,000), theresearchers said.

Even factoring in an 80 percent reduction

in equipment costs and higher working ca-

pacity, analysis showed that telehealth would

probably be eective, to 61 percent for a will-

ingness to pay 30,000 per QALY.

Telehealth was designed to have a num-

ber of benets to both patient and doctor,

including allowing patients to be more inde-

pendent and spend less time actively seek-

ing monitoring or care. Doctors can monitor

patients blood pressure or glucose levels, for

example, without scheduling unnecessary

visits.

These types of measures were thought

to reduce healthcare costs through fewer

doctor appointments and avoiding unnec-

essary treatments in favor of more effective

ones, particularly for patients with chronic

diseases. However, little quality data exist

on the association between outcomes and

costs.

Management of people with long-term

conditions is under the spotlight, given the

rapidly growing prevalence of such conditions

in aging populations, the researchers said.They added that the study raises further is-

sues such as targeting telehealth towards spe-

cic subgroups and the eects of livelihood

and demographics on telehealth ecacy and

costs that should be reviewed in subsequent

analyses.


21/39

21 May 2013 News

Freqent home relocations lined to

behavioral problems in some children

Laura Dobberstein

Moving to a new home more than

three times in the rst 5 years of

life may increase aention and

behavioral problems in economically disad-

vantaged children, according to a recent US

study.

Previous studies have linked frequent

moving to reduced academic performance,

greater rates of high school dropout, poorer

emotional and behavioral outcomes and low-

er levels of educational aainment.

Developmental psychologists have

shown that the home environment is one of

the most important inuences on young chil-

drens school readiness, noted study author

Dr. Kathleen Ziol-Guest, postdoctoral associ-

ate at Cornell University, Ithaca, New York,

US, and colleagues.

Ziol-Guest and her team examined data of

2,810 American children born between 1998

and 2000 from an existing study on new par-

ents and the welfare of their children. The par-

ents were interviewed at the hospital shortly

aer giving birth. Follow-up interviews weresubsequently conducted by telephone when

the child was 1, 3 and 5 years of age. In-home

assessments were also done when the child

was 3 and 5. The assessments included an in-

terview with the mother, an evaluation of the

home environment and an appraisal of the

childs health and development. [Child Dev

2013; doi: 10.1111/cdev.12105]

At the 5-year assessment, vocabulary andword identication tests determined lan-

guage and literacy outcomes and a checklist

monitored behavioral diculties.

Child gender, race, socioeconomic status

and parental education level and other de-

mographics were examined. Residential in-

stability was dened as moving at least three

times in the rst 5 years of a childs life, and

poverty was dened by the ocial federal

threshold.

Seventy-seven percent of the children in

the study had experienced at least one move

and 29 percent were residentially instable. Of

those dened as having residential instability,

44 percent were below the poverty threshold.

Residential instability was linked to aen-

tion problems, anxiousness, depression, ag-

gressiveness and hyperactivity among 5-year-

olds living in poverty. Language and literacy

outcomes and those who were not categorized

as poor were not aected by moving.

The authors speculated that frequent

moves may disrupt a childs socio-emotional

development. Social networks may also be

disrupted, creating an extra challenge for chil-

dren to make new friends. Feelings of frustra-

tion or anger may be displayed as behavioralproblems while test scores are less directly af-

fected.

Low-income families may move for dif-

ferent reasons than higher-income families,

they explained.

While some families choose to move be-

cause they are dissatised with their old

neighborhood or home, others have to move

in search of work, less expensive housing, oreven due to evictions and foreclosures.


22/39

22 May 2013 News

Speaking to Medical Tribune, Dr. Sun-

ny Im-Wang, pediatric psychologist and

school psychologist in San Francisco, Cali-

fornia, US, and author of Happy, Sad, &

Everything In Between: All About My Feel-ings said: Usually, frequent changes and

inconsistent environment [are] not good

for young children, adding that not all

children experiencing multiple moves will

have behavioral issues.

With lower-income families, the stress of

nancial issues puts burden on the family,which also impacts childrens behavior due to

familys stress, said Im-Wang.


23/39

23 May 2013 News

Vitamin D deficiency a concern for idney

transplant patients

Laura Dobberstein

Kidney transplant patients with vita-

min D deciency should consider tak-

ing vitamin D supplements in order

to prevent a decline in kidney function, say

French researchers.

Vitamin D is a critical hormone control-

ling mineral homeostasis, said Dr. Frank

Bienaime of the Universit Paris Descartes

and INSERM and Assistance Publique

Hopitaux de Paris, France, and colleagues.

It promotes phosphate and calcium ab-

sorption by the gut and increases calcium

reabsorption by the renal distal tubule,

thereby providing the positive calcium and

phosphorus ux required for bone mineral-

ization.

Bienaime and his team studied 634 pa-

tients who underwent a kidney transplant

to beer understand vitamin D levels at 3

months aer transplantation. The study ex-

amined vitamin D status in relation to early

mortality or transplant loss, the eciency

of the kidneys at 12 months as measured by

ow rate, and the health of the kidneys mea-sured through scarring and atrophy between

3 and 12 months.

The patients were evaluated over a 2- to

4-month period aer receiving the transplant.

The ow rate of ltered uid through the

kidney, known as glomerular ltration rate

(GFR), and vitamin D levels were measured.

Blood and urine samples were analyzed for

content and biopsies were examined for tu-

bular atrophy and scarring. [J Am Soc Nephrol

2013; Mar 28. Epub ahead of print]

During the course of the study, 19 of the pa-

tients were lost to follow-up, 30 patients lost

their transplanted kidney, 28 patients died

with a functioning transplant, and 3 died af-

ter losing their transplanted organ. Infection

was the most common cause of death and was

seen in 12 patients.

Deciency in vitamin D was shown to

correlate with lowered kidney function at 3

months aer transplant and increased kid-

ney scarring at 12 months aer transplant.

Other hormones associated with mineral me-

tabolism like calcium, phosphorus, calcitriol,

parathyroid hormone or broblast growth

factor-23 were not linked to kidney health.

Vitamin D deciency is a common problem

among those with impaired kidney function

but the status of the hormone aer having a

kidney transplant is not well understood.

The study authors encouraged future re-

search to evaluate the use of vitamin D sup-

plements in kidney transplant patients.[Our results] suggest that maintaining

vitamin D concentration within the normal

range would prevent renal function deterio-

ration aer renal transplantation, said Bein-

aime. Vitamin D supplementation, a simple

and inexpensive treatment, may improve

transplantation outcomes.


24/39

24 May 2013 Drug Profile

Dtasteride/tamslosin: Combination

therapy for BPH

The true prevalence of benign prostatic hyperplasia (BPH) in male populations has been

dicult to estimate due to the lack of a standardized denition. However, the characteristic

features of BPH abnormal proliferation of stromal and epithelial prostatic cells become

more common in men with age. The following article highlights the benets of dutasteride/

tamsulosin (Duodart, GlaxoSmithKline), a combination treatment consisting of two drugs

with complementary mechanisms of action, in patients with BPH.

Naomi Adam, MSc (Med),Category 1 Accredited Education Provider

(Royal Australian College of General Practitioners)

Introduction

Benign prostatic hyperplasia (BPH) is a

non-cancerous enlargement of the prostate

gland. Clinically, patients with BPH present

with lower urinary tract symptoms (LUTS) either voiding symptoms (eg, weak stream,

hesitancy, intermiency and abdominal

straining), and/or storage symptoms (eg, fre-

quency, nocturia, urgency and urge inconti-

nence). Voiding symptoms are more common

while storage symptoms are more bother-

some and interfere more with daily activities.

However, not all men with BPH suer from

LUTS, and conversely, not all men with LUTShave BPH.

The lack of a standardized denition of

BPH means that it is dicult to estimate its

true prevalence. In an aging male popula-

tion ( 80 years), the characteristic histologi-

cal features of BPH abnormal proliferation

of stromal and epithelial prostatic cells are

extremely common, seen in up to 80 per-

cent. When present, the symptoms can be

extremely bothersome and become more so

over time as the prostate enlarges and the

condition progresses. Eventually, complete

blockage of the urethra, known as acute

urinary retention (AUR), may occur. AUR

is a medical emergency that is oen unex-pected, painful and requires catheterization

to treat it. Following a rst episode of AUR,

the condition oen recurs, and 24 to 42 per-

cent eventually go on to have prostatectomy

surgery.

Guidelines developed at the 6th Interna-

tional Consultation on New Developments

in Prostate Cancer and Prostate Diseases

provide an algorithm for the management

of LUTS in men in the primary care seing.


25/39


[Male Lower Urinary Tract Dysfunction: Evalu-

ation and Management, 2006] The rst step is a

series of simple tests, and key among these is

the question as to whether patients nd their

symptoms bothersome. A large proportion ofmen who present are simply seeking reassur-

ance. Reports in the lay media oen errone-

ously state that geing up to urinate during

the night is a sign of prostate cancer, when in

fact it is quite normal for older men to get up

once per night.

For those who are not bothered by their

LUTS, no treatment is needed, just reassur-

ance. But in men who do nd their LUTS

bothersome, individualized medical therapy

should be used to address each patients pre-

dominant symptoms. There are several phar-

macological treatment options that should be

used according the underling pathophysiol-

ogy. [BJU Int 2011;107:1426-1431] Symptoms

of overactive bladder are most oen treated

with antimuscarinic agents. Symptoms asso-

ciated with obstruction due to prostatic en-

largement can be relieved with -blockers.

In men with moderate-to-severe LUTS and

an enlarged prostate, 5-reductase inhibi-

tors (5ARIs) reduce prostate volume and de-

crease urethral obstruction, providing con-

tinual symptom improvement and reducing

the risk of AUR and the need for surgery.

Dutasteride/tamsulosin hydrochloride

Mode of action

Dutasteride-tamsulosin is a combination of

two drugs with complementary mechanisms

of action to improve symptoms in patients

with BPH. [Duodart Prescribing Information]

Tamsulosin is an -blocker. Its action is

inhibition of sympathetic stimulation via

1-adrenoceptors. This provides relief fromLUTS symptoms by relaxing smooth muscle

in the bladder neck, prostate and bladder de-

trusor.

Dutasteride is the only licensed type 1 and

type 2 dual 5ARI. [J Clin Endocrinol Metab

2004;89:2179-2184] 5ARIs block the conver-sion of testosterone to dihydrotestosterone

(DH), which is the androgen primarily re-

sponsible for hyperplasia of glandular pros-

tatic tissue. This signicantly reduces prostate

volume in men with BPH. The enzyme 5-al-

pha reductase is present throughout the body

in two forms, or iso-enzymes: type 1 and type

2. Type 1 has been reported to be located pre-

dominantly in the skin, both in hair follicles

and sebaceous glands, as well as in the liver,

prostate, and kidney. Type 2 is found in the

male genitalia and the prostate.

Clinical ecacy

Recently, the CombAT study showed that

combination therapy with the -blocker tam-

sulosin and the 5ARI dutasteride eectively

treats LUTS due to BPH. [J Urol 2008;179:616-

621] The study population consisted of men

aged 50 years and over with a clinical diag-

nosis of BPH by medical history and physi-

cal examination. Those with total serum

prostate-specic antigen (PSA) greater than

10.0 ng/mL, a history or evidence of prostate

cancer, previous prostatic surgery or a his-

tory of AUR within 3 months before studyentry were excluded from the study. Subjects

were randomized to receive either tamsulosin

(n=1,611), dutasteride (n=1,623) or the combi-

nation of the two agents (n=1,610). There were

comparable rates of discontinuation between

the three groups, and 79 percent of the pop-

ulation completed the 24-month follow-up

visit.

The primary endpoint was the self-admin-istered International Prostate Symptom Score


26/39


(IPSS) questionnaire. At month 24, the aver-

age ( standard error) decreases in IPSS from

baseline were 6.2 ( 0.15) points for combina-

tion therapy versus 4.9 ( 0.15) and 4.3 ( 0.15)

points for dutasteride and tamsulosin, respec-tively. Compared with either monotherapy,

combination therapy also signicantly im-

proved urinary ow rate and reduced pros-

tate volume.

Adverse reactions

In the CombAT study, the total number of

drug-related adverse events (AEs) was higher

in the combination therapy group; however,

only 5 percent or fewer men withdrew from

the study due to an AE. The AEs more com-

mon with combination therapy were erectile

dysfunction, retrograde ejaculation, altered

(decreased) libido, ejaculation failure, de-

creased semen volume, loss of libido and nip-

ple pain. There were no instances of oppy

iris syndrome or breast neoplasms.

Dosing

The recommended dose of Duodart is one

capsule (500 g dutasteride /400 g tamsulo-

sin) taken orally approximately 30 minutes

aer the same meal each day. The eect of

renal impairment on the pharmacokinetics of

the active compounds has not been studied;

however, it is anticipated that no adjustment

in dosage would be needed. The medicationis contraindicated in patients with severe he-

patic impairment, and the eect of mild to

moderate hepatic impairment on pharmaco-

kinetics has not been studied.

Place within treatment guidelines

Guidelines published by the National In-

stitute for Health and Clinical Excellence

(NICE) state that men with moderate to se-

vere LUTS should be oered an -blocker.

A 5ARI should be oered to men with LUTS

who have prostates estimated to be larger

than 30 g or a PSA level greater than 1.4 ng/

mL, and who are considered to be at high risk

of progression (eg, older men). The combina-

tion of an -blocker and a 5ARI is therefore

appropriate for men with bothersome moder-

ate to severe LUTS and prostates estimated to

be larger than 30 g or a PSA level greater than

1.4 ng/mL. [The Management of Lower Urinary

Tract Symptoms in Men. National Clinical Guide-

line Centre, 2010.]


27/39

27 May 2013 In Practice

Managing rist pain

Dr. Eugene WongConsultant Orthopedic & Spine SurgeonAdjunct Assistant Professor

Perdana University Graduate School of Medicine

Serdang, Selangor, Malaysia

The wrist joint is an area bounded by the

distal radius and ulna proximally, andthe bases of the metacarpals distally.

The joints around the wrist comprise of the

distal radioulnar, radiocarpal and midcarpal.

Each of the surrounding structures can be the

site of injury, degeneration or disease and,

thus, a source of pain.

The location of wrist pain is indicative of

the cause. Patients may present with swelling

and pain localized to the radial aspect, dorsalaspect, ulnar aspect, palmar aspect or gener-

alized wrist pain.

With careful history taking, thorough

physical examination and imaging techniques

(plain radiographs, ultrasonography and

bone scintigraphy), a diagnosis of the cause of

wrist pain can be made in 78 percent of cases.

As the wrist can be aected by a multitude

of local and general disorders, it is oen dif-

cult to make an accurate diagnosis. In the

literature, wrist pain is generally subdivided

into traumatic or nontraumatic origin.Tendonitis is a common problem that can

cause wrist pain and swelling. Wrist ten-

donitis is due to inammation of the tendon

sheath. Wrist sprains are common injuries to

the ligaments around the wrist joint.

In the case of tenosynovitis of extensor ten-

dons, there is pain in the dorsum of the wrist

that may radiate proximally and distally.

There is a history of repetitive activities andoveruse. Pain occurs on exion and resisted

extension. Treatment of wrist pain caused by

tendonitis usually does not require surgery.

In exor tenosynovitis, pain is located on the

palmar aspect of the wrist, is aggravated with

wrist motion and with resisted wrist exion.

Carpal tunnel syndrome is the most com-

mon compression neuropathy in the upper

extremity. In carpal tunnel syndrome, the me-dian nerve is compressed as it passes through

the wrist joint. Patients oen complain of pain

around the wrist, numbness and tingling in

the radial three digits, clumsiness and weak-

ness. Patients frequently wake up at night

with numbness in the ngers.

Tinel test of the carpal tunnel and Phalen test

may be positive. Decreased sensibility in me-

dian nerve distribution and thenar atrophy arelate signs. A cockup wrist splint can be used.

Activity modication can be tried in work-re-

lated carpal tunnel syndrome. Surgical release

of the transverse carpal ligament is performed

when non-operative measures have failed, in

patients with constant numbness, motor weak-

ness, or increased distal median nerve motor

latency noted on electromyography.

A ganglion cyst is a swelling that usually oc-

curs over the back of the hand or wrist. These


28/39


are benign, uid-lled capsules. Ganglion

cysts are the most common mass on the dorsal

surface of the wrist. Most arise from the scaph-

olunate ligament. If the ganglion causes a pain

or severely limits activities, the uid may bedrained. Surgery involves removing the cyst

as well as part of the involved joint capsule or

tendon sheath. Even aer excision, there is a

small chance the ganglion will return.

Scaphoid fracture is most oen due to a fall

on an outstretched arm. There is tenderness

over the anatomic snuox. Undisplaced

fractures may be casted and a screw xation

done for displaced fractures.

Arthritis is a problem that can cause wrist

pain and diculty performing daily activi-

ties. Patients with inammatory arthritis and

osteoarthritis involving the radiocarpal, in-

tercarpal and carpometacarpal (CMC) joints

present with pain in the wrist.

Patients with osteoarthritis may have a

history of trauma. Swelling, stiness and de-

creased range of motion are present. Radio-

graphs of patients with osteoarthritis show

narrowing of the joint space, subchondral

sclerosis and osteophytes. Radiographs of pa-

tients with inammatory arthritis show nar-

rowing of joint space, osteopenia, bone ero-

sion and deformity. The arthritic carpal bones

can be excised. Joint fusion is done in cases

of severe pain. A wrist prosthetic implant isused to maintain pain-free range of motion.

De Quervain tenosynovitis is due to inam-

mation of the rst dorsal compartment of the

extensor tendons. There is a history of repeti-

tive wrist activities. The Finkelstein test (with

thumb exed into palm, pain is reproduced

by ulnar deviation of the wrist) is positive. An

anesthetic injection around the tendon sheath

can be given. Some patients may require sur-gical release of the rst dorsal compartment.

1. Scaphoid fracture 2. 1st CMC arthritis

3. Kienbocks disease 4. Carpal instability

5. TFCC tear

6. Ulnar impaction syndrome 7. De Quervain tenosynovitis

8. Pseudogout 9. Septic arthritic wrist

10. Ganglion cyst


29/39


In cases of distal radioulnar joint instabil-

ity, pain is located at the distal radioulnar

joint, especially with pronation and supina-

tion. Pain at the exor carpi ulnar is usually

detected on resisted wrist exion and ulnardeviation.

A triangular brocartilage complex (TFCC)

tear presents with ulnar-sided wrist pain, of-

ten with clicking. Pain is experienced with

axial load while rotating the ulnar-deviated

wrist. An arthroscopic repair can be done.

Immunocompromised patients or those

with a history of intravenous drug use are

at higher risk of wrist infection than the gen-

eral population. Pain, swelling, erythema,

decreased range of motion (ROM) and other

cardinal signs of infection may be present.

Increased pain with ROM is characteristic.

Elevated leukocyte count, erythrocyte sedi-

mentation rate (ESR) and C-reactive protein

are signs of infection.

Finding the cause of wrist pain begins with

a detailed history, physical examination and

the use of several diagnostic tests. X-rays of

the wrist are usually a rst step and will help

determine if more tests are needed. An ultra-

sound scan can be used to diagnose tendon

tears around the wrist. Magnetic resonance

imaging (MRI) is commonly used to evaluate

the wrist because it can show abnormal areas

of the so tissues. Blood tests are done to lookfor infection or arthritis.

Plain anteroposterior, lateral and oblique

radiographs are obtained to look for fracture,

with a carpal tunnel view for fracture of the

hook of the hamate. A scaphoid view is used

to assess scaphoid fracture. MRI may be use-

ful in the diagnosis of TFCC tear and wrist

infection.

The treatment of wrist pain depends en-tirely on the cause of the problem.

Radial wrist pain:

De Quervain tenosynovitis

Scaphoid fracture or non-union

Thumb CMC arthritis

Radiocarpal arthritis

Dorsal wrist pain: Tenosynovitis of extensor tendons

Ganglion cyst

Extensor carpi ulnaris tendinitis

Ulnar wrist pain:

Distal radioulnar joint instability

Flexor carpi ulnaris tendinitis

Fracture of the hook of the hamate

TFCC tear

Palmar wrist pain:

Flexor tenosynovitis

Carpal tunnel syndrome (CTS)

Palmar ganglionGeneral wrist pain:

Arthritis

Infection

Table 1: Regional distribution of wrist pain.

Mechanical causes:

Fracture

Non-union of scaphoid or hook of the hamate

Avascular necrosis of the scaphoid (Preisers disease)

or lunate (Kienbcks disease).

Triangular brocartilage complex Distal radioulnar joint subluxation

Carpal instability

Scapholunate dissociation

De Quervains tenosynovitis

Intersection syndrome

Neoplasm or ganglion

Neurologic causes:

Distal posterior interosseous nerve syndrome

Injury of median nerve (carpal tunnel syndrome)

Injury of radial nerve

Injury of ulnar nerve (Guyons canal)

Thoracic outlet compression syndrome

Systemic causes:

Amyloidosis

Granulomatous disease (eg, sarcoid, tuberculosis)

Hematologic disease (eg, leukemia, multiple myeloma)

Metabolic conditions (eg, acromegaly, diabetes, gout,

hyperparathyroidism, hypocalcemia, hypothyroidism,

Pagets disease, pregnancy, pseudogout).

Osteomyelitis

Peripheral neuropathy

Reex sympathetic dystrophy (complex regional pain

syndrome).

Rheumatologic disorders (eg, psoriasis, rheumatoid

arthritis, scleroderma, systemic lupus erythematosus).Table 2: Etiology of wrist pain.


30/39


Rest and activity modication: The rst

treatment for many common conditions

that cause wrist pain is to rest the joint, and

allow the acute inammation to subside. It

is important, however, to use caution whenresting the joint because prolonged immo-

bilization can cause a sti joint. Adjusting

activities so as not to irritate the joint can

help prevent worsening of wrist pain.

Ice and heat application: Ice packs and

heat pads are among the most commonly

used treatments for wrist pain.

Wrist support: Support braces can help pa-

tients who have either had a recent wrist

sprain injury or those who tend to injure

their wrists easily. These braces act as a gen-

tle support for wrist movements. They will

not prevent severe injuries, but may help

the patient perform simple activities while

rehabilitating from a wrist sprain.

Anti-inammatory medication: Nonste-

roidal anti-inammatory drugs (NSAIDs)

are some of the most commonly prescribed

medications, especially for patients with

wrist pain caused by arthritis and tendon-itis.

Cortisone injections: Cortisone is used to

treat inammation which is a common

problem in patients with wrist pain.

Some wrist conditions require arthroscopy

for diagnosis or treatment. Arthroscopic sur-

gery is a treatment option available for some

causes of wrist pain such as TFCC tear and

arthritis. In cases of severe pain arising from

arthritis, wrist replacement or fusion may be

required.

A detailed history taking, clinical exami-

nation and appropriate imaging will identify

the cause of wrist pain. Diagnostic injections

are sometimes needed.


31/39

31 May 2013 After Hours

GettinG Around on the

London underGroundJoseph Hoye

There may be bigger and there may be

busier, but no one can deny the Lon-don Underground its place in history

as the worlds rst underground rail system.

It has inspired poetry, featured in lms and

been the subject of countless documentaries

and magazine articles. Reviled occasionally,

praised sporadically, it is the pulsing artery of

a sprawling city that depends on mass transit

to stay alive. For most Londoners, it is just a

fact of life. To visitors, it can be fascinating,horrifying and rewarding oen within the

same journey.

One hundred and y years ago, the

worlds rst underground railway opened.

The Metropolitan Railway hauled 38,000 pas-

sengers on its rst day in January 1863, travel-

ing the 6 kilometers between Paddington and

Farringdon. A broad gauge railway, the loco-

motives were steam powered and the wooden

carriages were illuminated by gas lamps.

Jump forward to today. From that single

line of 6 kilometers, there now runs 402 kilo-

meters of electried track with trains servic-

ing 270 stations across 26 London boroughsand into neighboring counties.

Its history and culture is rich. Ghosts

abound, civilians took shelter during bomb-

ing raids, US talk-show host Jerry Springer

was born in the Underground. Theres even

a book chronicling the mice of the Under-

ground. Ever wondered which station you

keep seeing in London lm sets? Good odds

that its the disused Aldwych station on thePiccadilly line. Patriot Games, V For Vendea

and Atonement are amongst the many lms

to use this station.

Using the Tube

With its bustling 3.5 million passengers

each day, it can be dicult to negotiate the

Tube. It may seem like chaos but the London

Underground does have an etiquee that

helps keep the system moving. Some of these


32/39


33/39


the Heathrow Express is out of action or the

motorways are snarled up.

London isnt just the inner city. Harrow,

Kew Gardens, Wimbledon and Europes larg-

est shopping centre Westeld Stratford areall directly accessible via the Tube.

There are occasions when the Under-

ground is not a travel option. London also

has a very good overland rail service as well

as an excellent bus service - some of the bus

routes operate a 24-hour service. Do not dis-

count Londons famous black cabs as a way

to move around the city but do be aware that

longer trips can be somewhat pricey and

trac holdups can last several hours. Fi-

nally, the River Thames is also a great option

for anyone wanting to move quickly or see

many of Londons famous landmarks. HMS

Belfast, originally a light cruiser for the Royal

Navy and now a museum ship permanently

moored on the river, is particularly daunting

when seen from the deck of a ferry.

And it is easy to walk the streets of Lon-

don. Wandering a 500 meter radius around

Trafalgar Square nets the National Gallery,Downing Street, Horse Guards, Piccadilly

Circus, Leicester Square, Covent Garden and

the Thames. Sometimes, Shanks pony is the

best way to get around London but for the

rest of the time, choose the Tube.

London has much to oer, whether you

live there or are just passing through for a

few days. Theaters, restaurants, football, mu-

seums: all are world class and all owe a debt

to the Underground. It is as much a part of

the city as the Tower of London or Tate Britain

and is rightly celebrating 150 years of service.

Used to get from A to B or enjoyed in its own

right, the Tube is Londons underground su-

perstar.


34/39


BIkING THE

GOLDEN GATE BRIDGERadha Chitale

The Golden Gate Bridge cuts a russetswoop across the San Francisco skyline.Completed in 1937 to connect the main

part of the city to its rapidly expanding north-

ern counties, the bridge has always been opento pedestrian trac. Graced with sunny weath-er on a recent trip to San Francisco, I thoughtthe best way to experience this icon of modernarchitecture up close would be a leisurely cycle.

I started at Fishermans Wharf, the center ofSan Franciscos historical shing district and apopular tourist spot. The sta at Blazing Sad-dles, a bicycle rental company, outed me with

a bike, helmet, lock and water, and mapped outwhat would be a 13-kilometer ride hugging theSan Francisco Bay, across the bridge and downto Sausalito in Marin County where I could

catch a ferry back to the city. The whole ridewould take about 2-and-a-half hours.

The route to the bridge is mostly at butthere are several steep hills that I, less thantoned through the quadriceps, had to walk up.

The rst incline came almost immediately

aer I set o from Hyde Street. Pushing my bi-cycle up the hill did give me time to admire aclear view of the bay and Alcatraz Island, oncethe site of the famous high-security prison.

Beyond that rst very short hill was FortMason Green and further, Crissy Field, thenorthern edge of The Presidio park. The qui-et, green ride required no great eort, so Itook my time, snapping too many photos ofsailboats cuing through the bay.

Having rested suciently, I chose not toaempt the next and steepest portion of theride as the path climbs upwards in order to


35/39


go from sea level to the base of the bridge 67meters above, and instead enjoyed watchingmore able cyclists chug past me.

The distinctive orange bridge loomed large

as soon as I crested the hill, a span suspensiondesign in which the roadway hangs o verti-cal suspenders aached to cables strung be-tween 227-meter high towers. The simple rail-ings, vertical ribbing and diminishing towersare hallmarks of art deco style, popular in the1930s. The whole structure looks delicate fromafar but the main cables are almost 1 meter indiameter and the total weight of the bridge isover 800,000 metric tons.

I made my way under the bridge to thewest side where cyclists could get on the foot-path. Safety signs warn about high windswhile crossing; but while the winds did notinterfere with my balance, I certainly couldhave used some gloves and an extra sweaterunder my down vest.

My discomfort was more than compensat-ed by the expanse of the Pacic Ocean and the

gentle green hills of Marin County. Some careis necessary when riding, as there are severalblind turns as the footpath curves around themain towers, but small outcroppings of foot-path allow a place to rest or take pictures clearof passing cyclists and pedestrians.

The gradual incline I felt as I pedaled start-ed to give as soon as I passed the halfwaypoint and I quickly reached the far side of the

bridge. Out of the sun it was chilly and I de-

bated continuing on to Sausalito, an unknownroute, or head back the way I came.

A fellow cyclist advised me to continueon and catch the ferry, saying it was an easy20-minute ride. In the future, I will be morewary of pro-looking cyclists in bright yellow

biking shorts who tell me a hill is not bigbecause once again I found myself pushingmy bicycle uphill. However, the subsequent

coast into picturesque Sausalito was enjoy-able.

With just enough time for a restorativecoee, I caught the last ferry back to thePort of San Francisco. I hopped on my bikeagain and cycled up the Embarcadero back

to Fishermans Wharf to return it, 4 hoursaer I began.

DID YOu kNOw?The Golden Gate Bridge has always been

painted International Orange, chosen tocomplement the warm colors of the sur-rounding land masses and contrast withthe cool blues of sea and sky, which alsomakes it more visible to passing shipsthrough the Bay fog.The bridge towers have fewer lights to-wards the top to appear more majestic atnight, as if they soared beyond illumina-

tion.The Golden Gate Bridge was only the lon-gest suspension bridge in the world until1964, but it is still the most photographed

bridge in the world.The bridge can expand or contract by upto 16 feet when the temperature changes.It has appeared prominently in a numberof lms including Superman (1978), Inter-view with a Vampire (1994) and The Rock

(1996).


36/39

36 May 2013 Humor

I think, if u lsen ur belt a little,u wnt be exerienin thse terrible hest ains!

Dnt tr t hide under thse masks. I knw wh u are!

Whatever it is in arund,u have it!

Just make sure u dnt takethese sleein ills and a laxative

n the same niht!

She an frive Lane Armstrnbut she ant frive me!

I knw u must be in a lt fain, but lets be ttall fair.

This is ur niht t d the dishes!


37/39

37 May 2013 Calendar

MAy

American Urology Association (AUA) Annual

Meeting

4/5/2013 to 8/5/2013

Location: San Diego, California, USInfo: AUATel: (1) 410 689 3700Fax: (1) 410 689 3800Email: [email protected]: www.aua2013.org

46th Annual Meeting o the European Society

or Paediatric Gastroenterology, Hepatology and

Nutrition

8/5/2013 to 11/5/2013Location: London, EnglandInfo: ESPGHAN Organizers

Tel: (44) 845 1800 360Email: [email protected]: www.espghan2013.org

9th Asian Society or Paediatric Research

Congress

9/5/2013 to 12/5/2013Location: Kuching, MalaysiaInfo: ASPR-PSM 2013 Congress SecretariatTel: (603) 4023 4700, 4025 4700, 4025 3700Website: www.aspr-psm2013.org

20th European Congress on Obesity

12/5/2013 to 15/5/2013Location: Liverpool, EnglandInfo: ECO2013 SecretariatTel: (44) 20 8973 2506Email: [email protected]: www.easo.org/liverpool-eco-2013

Diabetes Preventing the Preventables Forum

24/5/2013 to 26/5/2013Location: Kuala Lumpur, MalaysiaInfo: Asia Diabetes FoundationTel: (852) 2637 6624

Fax: (852) 2647 6624Email: [email protected]: www.adf.org.hk/dpp2013

12th Congress o the European Association or

Palliative Care

30/5/2013 to 2/6/2013Location: Prague, Czech RepublicInfo: European Association for Palliative CareTel: (49) 89 548234 62Fax: (49) 89 54823443Email: [email protected]: www.eapc-2013.org

American Society o Clinical Oncology Annual

Meeting

31/5/2013 to 4/6/2013Location: Chicago, Illinois, USInfo: ASCO Customer CareTel: (1) 888 282 2552 or

(1) 571 483 1300Website: http://chicago2013.asco.org

World Congress o Nephrology

31/5/2013 to 4/6/2013Location: Hong KongInfo: ISN World Congress of Nephrology 2013Tel: (852) 2559 9973Fax: (852) 2547 9528Email: [email protected]: www.wcn2013.org

JUNE23rd Conerence o the Asian Pacifc Association

or the Study o the Liver

6/6/2013 to 9/6/2013Location: SingaporeInfo: APASL SecretariatEmail: [email protected]: www.apaslconference.org

International Digestive Disease Forum 2013

8/6/2013 to 9/6/2013

Location: Hong KongInfo: UBM Medica Pacific LimitedTel: (852) 2155 8557Fax: (852) 2559 6910Email: [email protected]: www.iddforum.com

3rd World Congress o Thoracic Imaging

8/6/2013 to 11/6/2013Location: Seoul, KoreaInfo: WCTI SecretariatTel: (82) 2 3452 7245/(82) 2 3471 8555Fax: (82) 2 521 8683

Email: [email protected]: www.wcti2013.org

17th International Congress o Parkinsons

Disease and Movement Disorders

16/6/2013 to 20/6/2013Location: Sydney, AustraliaInfo: MDS Congress StaffTel: (1) 414 276 2145Fax: (1) 414 276 3349Email: [email protected]: www.mdscongress2013.org


38/39

38 May 2013 Calendar

American Diabetes Association

73rd Scientifc Sessions

21/6/213 to 25/6/2013Location: Chicago, Illinois, USInfo: ADA Registration Customer Care CenterTel: (1) 415 268 2086

Email: [email protected]: http://scientificsessions.diabetes.org

UpcoMINg

9th Asian Dermatological Congress

10/7/2013 to 13/7/2013Location: Hong KongInfo: ADC 2013 SecretariatTel: (852) 3151 8900Email: [email protected]

Website: www.adc2013.org

13th Asian Federation o Sports Medicine

Congress

25/9/2013 to 28/9/2013Location: Kuala Lumpur, MalaysiaInfo: AFSM OrganizersEmail: [email protected]

Website: www.13afsm.com

13th International Workshop on Cardiac

Arrhythmias - VeniceArrhythmias 2013

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

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


39/39

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