NEWS & INSIGHTS

PHILIPPINES

MAY 2016

CAMEO_AD_NewLogo-New-CC.pdf

Amidst concern by
stakeholders, DOH
vouches for the safety
of dengue vaccine

FORUM

PHILIPPINE FOCUS

World needs new

approaches to
prevent infections

Whats in an RxBox?
Tools to save lives

CONFERENCE
COVERAGE

FEATURE

HOPE-3 supports statins

with or without BP drugs
for reducing CV events

The diabetologist as a
diabetes patient

15/10/15

10:16 am

MAY 2016 2

Amidst concern by stakeholders,

DOH vouches for the safety of
dengue vaccine
DR MEL M. BELUAN

he WHO and the Department of Health

(DOH) have recently allayed fears regard-

ing the safety of CYD-TDV (Dengvaxia), the vaccine being administered in the ongoing dengue
vaccination program in public schools in Metro
Manila, Calabarzon and Central Luzon.
Following the start of the program, the WHO
Strategic Advisory Group of Experts on Immu-

said that the countrys dengue vaccination pro-

nization (SAGE) just released its recommenda-

gram is consistent with the SAGE recommen-

tions on the dengue vaccine. SAGE states that

dations, and the WHO will continue to support

because of the higher risk of hospitalization and

DOHs efforts. As of April 24, the DOH reported

severe dengue observed in ages 2 to 5, the

that 204,397 students were already vaccinated.

vaccine is not recommended in ages under 9.

It says that it is up to the country concerned to

Worried advocacy groups

decide the target ages for routine vaccination

Prior to the release of the SAGE recom-

based on endemicity and feasibility. While it is

mendations, public health advocates had ex-

responsible for recommending global policies,

pressed their apprehension of the dengue

SAGE does not handle the licensure approval

vaccination program which was implemented

of vaccines in each country.

ahead of WHO recommendations and prequal-

Professor John Abramson, SAGE chair, re-

ification. In a forum, Dr Anthony Leachon, Phil-

portedly said in a news conference in Geneva,

ippine College of Physicians Foundation presi-

The number one main recommendation is that

dent, noted that the WHO Prequalification of

this vaccine is efficacious and safe but should

Medicines Programme, which helps ensure

be only used in populations where the disease

that resource-poor countries have access to

incidence in the population is at least 50 per-

much-needed medicines, can lower the price

cent.

of the vaccines.

In a forum hosted by DOH on April 18, 2016,

Dr Antonio Dans, an epidemiologist with

Dr Gundo Weiler, WHO country representative,

the University of the Philippines-Manila, also

MAY 2016 3

cited the possibility of the vaccines causing an

on April 4, 2016, the DOH has reported that

antibody-dependent enhancement (ADE) in

362 recipients had adverse events. The

which although at first, the vaccines may de-

most common effects were fever, head-

crease the incidents of dengue, they may sub-

ache, dizziness, vomiting and rash. Exclud-

sequently result in severe disease for repeat

ed from the adverse events list is the death

infections.

of an 11-year-old male 12 days after he was

May-i Fabros of Womanhealth Philippines

vaccinated.

also cautioned, We appeal to the DOH to ex-

DOH secretary Janette Garin said the cause

ercise prudence in the interest of our childrens

of death was not related to the vaccine, as

safety. Womanhealth Philippines is part of

the immediate cause of death was pulmonary

the Alternative Budget Initiative for the Health

edema in a background of acute gastroen-

Cluster which closely monitors the expenditure

teritis, mild dehydration and congenital heart

in public healthcare.

disease. Based on the assessment of the National Adverse Event Following Immunization

Adverse events
Since the start of vaccination program

Committee (NAEFIC), Garin said that the vaccination was coincidental.

Study shows effective dengue

surveillance tool in schools

study done by Drs Lilian De Las Llagas,

outbreak prevention, said De Las Llagas in a

Lisa Grace S. Bersales of the Univer-

press statement.

sity of the Philippines Manila (UPM) and col-

The School-based Mosquito Abundance

leagues, and backed by the Philippine Council

Model, or SMAM, study hinges on a model that

for Health Research and Development, reveals

predicts the patterns of the so-called the ovitrap

how a model can estimate mosquito density

index (OI), an effective mosquito surveillance

in public Philippine elementary and second-

tool, in schools found throughout the countrys

ary schools even without utilizing active vector

four climates types. The study was based on

surveillance.

data obtained from July 2015 to February 2016.

We are offering this model as a science-

Data collection will extend to the second quar-

based contribution to the dengue control ef-

ter of 2016 to come up with a 12-month profile

forts. The results will be an important pre-

for prediction. At the studys conclusion, a De-

diction for dengue cases and eventually for

partment of Science and Technology website

MAY 2016 4

will be showing areas where dengue transmis-

Ovitraps replicate the natural breeding condi-

sion is high.

tions of mosquitoes.

SMAMs aim is to help address the problem

SMAM serves as an early warning device to

related to rising dengue cases, such as ineffec-

prompt the communities to do an aggressive

tive disease prevention and control and pest

mosquito search and destroy activities because

surveillance measures. The researchers said

their school is at risk of having dengue trans-

that using the ovitrap system and the OI can

mission, said De Las Llagas and Bersales said

help assess the risk of dengue transmission.

in a statement.

MAY 2016 FO R U M 5

World needs new diagnostics,

replacement antimicrobials and more
vaccines to prevent infections
Excerpted from the speech by Dr Margaret Chan, WHO director-general,
during the European Union Ministerial Conference on Antimicrobial Resistance held in Amsterdam, the Netherlands on February 10, 2016.

or more than a decade, the European

Union has been a world leader in the

struggle to combat AMR. This is readily appar-

ent in the number of policies, directives, technical reports, strategies, and regulatory decisions
designed to reduce antibiotic consumption, in
humans and animals, ensure the prudent use
of these fragile medicines, and protect specific
agents that are critically important for human
medicine.

demand for meat as household incomes im-

You have moved forward in remarkable ways,

prove. This growing demand, especially when

as reflected in several EU-wide networks for

met by intensive farming practices, contributes

surveillance of both resistance and consump-

to the massive use of antibiotics in livestock

tion, and for susceptibility testing.

production.

Significantly, the EU-wide ban on the use of

Worldwide, we need to insist that risks to hu-

antibiotics as growth promoters in animal feed

man health guide the prudent use of antibiotics

has not weakened the regions leading position

in food production. The WHO list of critically im-

in global food production.

portant antimicrobials for human medicine pro-

Compelling evidence shows that resistance

vides a tool for doing so.

is driven by the total volume of antibiotics used,

The world certainly needs to feed its nearly

also in food production. Worldwide, antibiotic

7.4 billion people, but not in ways that cause

use in humans, animals, and agriculture is still

our mainstay antimicrobials to fail. Combatting

increasing, despite effective reductions in some

antimicrobial resistance, in line with the global

countries.

action plan, is a matter of the utmost urgency.

In several large emerging economies, stud-

The health sector, acting alone, cannot possi-

ies have consistently documented a rise in the

bly contain a threat of this magnitude. We need

MAY 2016 FO R U M 6

to work together with partners. Conferences like

As colistin had not been widely used, it was

this one can move a broad agenda forward as a

still effective. It was also cheap, which encour-

model for the rest of the world.

aged its massive use as a growth promoter in

We face a crisis. We are hearing one alarm

bell after another. Minister Schippers mentioned

food production in several countries, including

China.

Zika and Ebola, two cross-border epidemics

The Chinese findings, which have been rep-

that are currently ongoing. We are meeting here

licated in several other countries, solidify the

today to discuss AMR, another cross-border

links between the agricultural use of antibiotics,

slow moving tsunami. Early warnings have been

resistance in slaughtered animals, resistance in

issued on AMR and its impact. We must act.

food, and resistance in humans. All of the dots

I urge you to agree on the strongest possible

are connected.

action plans. I urge you to establish an aggres-

If we lose colistin, as several experts are pre-

sive model for the rest of the world to follow. I

dicting, we lose our last medicine for fighting a

urge you to make the kind of noise that signals

number of serious infections.

the need for action on a scale appropriate to the

magnitude of this crisis.
Let me focus on one of the most recent of
these alarm bells relevant to AMR. The detec-

This is a crisis, and it is global. Resistant

pathogens travel well internationally in people,
animals, and food. They can also spread directly from one person to another.

tion last year by Chinese scientists of a new

In some countries, as many as 35 percent of

resistance mechanism, the mcr-1 gene, sent

newly detected tuberculosis cases are infected

shockwaves through the medical and scientific

with multi-drug resistant strains right at the start,

communities.

indicating direct person-to-person transmis-

The gene is located on a mobile loop of DNA

sion, not faulty treatment.

that transfers easily from one bacterial strain

We need to take heed of the repeated warn-

to others. This is a horizontal transfer of resis-

ings. I have been asked by my colleague,

tance, and it is frightening.

Monique Eliot, to convey to you the deep en-

In the Chinese study, the mcr-1 gene con-

gagement of the World Organisation for Animal

ferred resistance to colistin, the last-resort an-

Health, or OIE, which she heads. I am pleased

tibiotic used to treat several life-threatening

to do so.

infections caused by Gram-negative bacteria.

OIE and FAO played a major role in shap-

Resistance to colistin was detected in samples

ing last years global action plan. As part of this

from animals and humans and in food.

tripartite effort, under the one health banner,

Colistin is a 50-year-old antibiotic that was

the governing bodies of both agencies adopted

shelved in the 1970s because of its toxic effects

resolutions supporting the action plan last year.

on the kidneys. It was brought back into clinical

Together, we have produced a manual and

use when all newer antibiotics began to fail.

checklist to support the implementation of na-

MAY 2016 F O R U M 7

tional action plans. We all share the view that

chain and issues the WHO list of critically im-

the use of antimicrobials should be supervised

portant antimicrobials.

by medical and veterinary professionals.

The news from this surveillance is not good.

Relevant OIE standards promote the respon-

We face huge gaps in our ability to monitor the

sible and prudent use of antibiotics in animals

situation in many countries. As this is a global

to preserve their efficacy and prolong their use

crisis, we need to close these gaps.

in both veterinary and human medicine.

We need new diagnostics as well as replace-

The three agencies collaborate very well

ment antimicrobials and more vaccines. We

through formal mechanisms, such as the Advi-

need to find the business models and incentives

sory group on the integrated surveillance of an-

to stimulate the relevant research and develop-

timicrobial resistance. The group keeps close

ment. We need to do more to prevent infections

watch over the use of antibiotics in the food

in the first place.

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MAY 2016 P H I L I P P I N E FO C U S 8

Diabetes knowledge in the rural

community remains poor
DR CAROL TAN

he overall knowledge of patients on diabetes mellitus in the rural community is

unsatisfactory, according to a new study by Dr

Gregory Joseph Ryan A. Ardea et al.
The study served as the Phase 1 or the Community Assessment Phase of a five-year program on community diabetes care. The authors
aimed to evaluate the baseline knowledge, at-

titudes and practices of patients with type 2

diabetes mellitus in the rural community, since
these are crucial factors in improving diabetes
control and the overall health of these patients.
[Diabetes Res Clin Pract 2010;90:160-6]

A total of 156 patients were included in the

The authors conducted a cross-sectional

study. The mean age was 57 years old, with

analytic study involving patients diagnosed

a range of 34 to 91 years. The majority of the

with type 2 diabetes mellitus in San Juan,

study participants were female (67 percent),

Batangas. Stratified cluster sampling was used

unemployed (72 percent) and unable to receive

to select participants. The inclusion criteria in-

high school education (72 percent). Fifty-six

cluded age of at least 18 years old, ability to

percent of the participants had the disease for

speak and understand the Filipino language,

only less than a year. Oral antidiabetic agents

and willingness to answer questionnaires and

were given to 63 percent of the participants,

participate in focus group discussions. Data

while 32 percent were maintained on diabetic

collection was conducted using the Ameri-

diet alone. The majority of the participants ex-

can Association of Clinical Endocrinologist

perienced peripheral extremity numbness (94

Knowledge Evaluation Form and the Diabe-

percent) and blurring of vision (80 percent).

tes Attitude Scale developed by the University

The mean score of the participants on the

of Michigan Diabetes Research and Training

Knowledge Evaluation Form was 43 percent,

Center. These questionnaires were translated

with a range of 13 to 83 percent. The scores

into the Filipino language and validated in

were found to be significantly affected by the

previous studies.

age and educational attainment of the respon-

MAY 2016 P H I L I P P I N E FO C U S 9

dents. Older patients obtained lower scores

a glucometer for self-monitoring of blood glu-

with a p-value of 0.026, while those with higher

cose.

educational attainment had higher scores with

a p-value of 0.046.

The authors explained that Diabetes SelfManagement Education (DSME) has long been

Assessment of diabetes-related attitudes re-

recognized as a fundamental component of

vealed that only one percent of the participants

diabetes care. The DSME ensures that diabetic

considered diabetes mellitus as a serious dis-

patients have adequate knowledge and skills to

ease, and only ten percent believed that it was

make self-adjustments to their medications, diet

cost-effective to spend for the necessary equip-

and physical activity. The effectiveness of the

ment, medications and laboratory tests to ob-

DSME is largely affected by the patients base-

tain good glucose control. Moreover, only 38

line knowledge, attitude and practices, thus

percent believed they should be the primary

highlighting the importance of careful evalua-

decision-makers in the management of their

tion prior to conducting the program.

diabetes.

The authors concluded that the data derived

Diabetes practices were better compared

from this phase I study should be incorporated

with the knowledge and attitude, with 72 per-

into the educational materials of the proposed

cent of the participants seeking consult with a

DSME program in order to increase cultural sen-

rural health unit officer, barangay health worker,

sitivity and relevance of the program. Further-

and medical resident or medical intern. The fre-

more, the results and processes of this study

quency of consults varied from monthly to every

may also be applied to other rural communities

six months. However, only 11 percent owned

with similar background.

Filipina, young and overweight?

You may be at risk of inflammation
during pregnancy
DR JAMES SALISI

conducted by Thomas W McDade and colleagues published in The Journal of Nutrition

eing overweight and having inflammation

recently. With the rise of overweight and obe-

in young adulthood before pregnancy are

sity around the world, the researchers wanted

strong predictors of inflammation in the third

to find out whether adiposity and inflammation

trimester of pregnancy, according to a study

in young women were predictors of inflamma-

MAY 2016 P H I L I P P I N E FO C U S 10

tion in the third trimester of pregnancy. [J Nutr

2016;146:353-7]
They recruited a total of 309 women who
were 24 to 30 years old from the Cebu Longitudinal Health and Nutrition Survey between 2009
and 2014, collecting data pregnancy information, anthropometric measurements, and blood
sample from a total of 409 pregnancies. They
used data collected in 2005 and 2009 to assess
body mass index (BMI) and C-reactive protein
(CRP) an inflammation marker in young

the increased risk of cardiovascular and meta-

adulthood before the subjects became preg-

bolic diseases among Asians, including Filipi-

nant. After applying regression models, they

nos, the rate of obesity/overweight increased

found that the levels of overweight/obesity and

to 27.3%. The majority of study participants

inflammation in young adulthood are strong

also had a mean waist-hip ratio of greater than

predictors of inflammation in the third trimester

0.85, the WHO cutoff for increased metabolic

of pregnancy.

risk.

The study participants were contacted at

The researchers considered several vari-

6-month intervals to identify new pregnancies

ables as potential confounders or modifiers

over a period of five years. When a pregnancy

of associations with pregnancy CRP and con-

was detected, an in-home interview was sched-

trolled for them. These variables included so-

uled for the third trimester. Anthropometric

cioeconomic status (education level, home

measures, household demographic data and

ownership, assets) and information on preg-

blood samples were collected. BMI data from

nancy complications (including self-reports of

2009 were used to define pre-pregnancy BMI

gestational diabetes, high blood pressure, uri-

unless women were pregnant at the time of the

nary tract infection and placenta previa). Almost

survey, in which case BMI values from 2005

a fifth of the pregnancies were associated with

were used. Out of the 309 women, 89 women

one or more complications.

were pregnant twice and 11 women were preg-

McDade and colleagues found that pre-preg-

nant 3 times, and in total, 409 pregnancies were

nancy BMI was a stronger predictor of third-

included in the study.

trimester circulating CRP than BMI in the third

Using the WHO-recommended values, a

semester. They found no association between

total of 15.3% of the women were overweight

pregnancy weight gain and CRP. However, pre-

or obese as young adults before pregnancy.

pregnancy CRP was found to be a significant

When the BMI cutoff value was adjusted to 23

predictor of CRP in pregnancy, independent of

as overweight and 25 as obese to account for

BMI.

MAY 2016 P H I L I P P I N E FO C U S 11

It is the first study to report an association

has been associated with poor birth outcomes

between the level of inflammation during adult-

globally. What is clear is that attention ought to

hood, before pregnancy, and the inflammatory

be focused on the contribution of overweight

response to pregnancy. While pregnancy is

and obesity to adverse birth outcomes. Strat-

considered an inflammatory event, the regula-

egies to limit weight gain may have to be ex-

tion of which is important in having a healthy

panded not only during pregnancy but also be-

pregnancy, the extent to which overweight or

fore it happens, in order to reduce the levels of

obesity before or during pregnancy contributes

inflammation. The researchers opened up the

to excessive inflammation was not known.

possibility of future research on factors that con-

Although the clinical implications of their

findings are not clear, excessive inflammation

tribute to inflammation during pregnancy and its

implications for birth outcomes.

Social media strategy enhances

public health response in times
of disaster
DR JAMES SALISI
S ocial media strategy enhances public
health response in times of disaster, according
to a report by a team at the Office of the World
Health Organization Representative in the Philippines on their experience in the aftermath of
Typhoon Haiyan. This is one of the most important lessons they learned in their emergency
response work as they established Facebook,
Twitter and Instagram presence to reach the

Non-emergency situations are the best times

general public. Social media was used to dis-

to start a social media strategy but the WHO of-

seminate public health information that evolved

fice in the Philippines had had no social media

as the situation and types of risk changed after

presence when Typhoon Haiyan struck. Other

the disaster. [Western Pac Surveill Response J

than the mainstream media and a website

2015; 6(Suppl 1):8690]

where they published bi-weekly health cluster

MAY 2016 P H I L I P P I N E FO C U S 12

bulletins and early warning alert and response

as well as alignment of social media messag-

reports, they had no other digital platform to

ing between the two agencies boosted the

reach the people. With over 16 million people

number of people reached per post. The social

affected and extensive damage in infrastruc-

media team analyzed the number of followers

ture, traditional communications channels were

and posts on Facebook and Twitter accounts

not enough to communicate emergency risk to

between November 27, 2013 and January 30,

the public.

2015 and found that these changes resulted in

Recognizing the power of social media to

further reach. For example, an infographic on

reach people and that the Philippines has over

breastfeeding in disasters reached seven times

34 million active Facebook users, the WHO of-

more people than a photo and a text during the

fice in the Philippines quickly established social

same period.

media accounts a week after telecommunica-

Collaboration with partners such as UNI-

tions were put back on line in affected areas.

CEF and the Department of Health and NGOs

They prioritized developing content for their

was also an opportunity to increase social me-

Facebook account over Twitter and Instagram

dia coverage. A campaign called Health at the

because there were more Facebook users in

Heart of Healing called for people to post pic-

the Philippines especially in rural areas only

tures of themselves making a heart symbol with

40 percent of social media users in rural popu-

their hands as support for those affected by the

lations use Twitter, for example.

typhoon. It generated 170 entries from partici-

The messages and information posted on

pants that included Philippine government of-

these social media accounts evolved, as the

ficials, Health Cluster partners, health officials,

situation after the typhoon hit changed from

overseas Filipino workers and WHO staff in the Eu-

acute response to recovery. Initially, the posts

ropean Region and Region of the Americas. This

were about the WHO emergency response told

in turn generated attention from traditional media.

through photos and text. As the situation shifted

Although the social media team at the WHO

from response to recovery, these types of posts

country office was not able to measure the

were replaced with public health messages that

actual success and effectiveness of the strat-

encouraged people to act in order to prevent

egy, which was developed during the response

public health threats such as waterborne diseas-

phase, they established the importance of a

es, unsanitary conditions and the spread of vac-

social media strategy during and more impor-

cine-preventable diseases. Infographics were

tantly before a disaster. In addition, because

also used to present these messages and in fact

of their experience, evaluation of social media

generated further reach and more followers.

strategy has been added to the updated WHO

In addition to changes in content and pre-

Emergency Risk Communication standard op-

sentation, technical input and expert advice

erating procedures for implementation in future

from both WHO and the Department of Health

emergencies.

MAY 2016 P H I L I P P I N E F O C U S 13

PTSDs underlying dimensions

among Typhoon Haiyan survivors
revealed
GABRIEL ANGELO SEMBRANO

DSM-5. Each item was to be rated 0 (not at all)

to 4 (extremely), with a higher score implying

ost-traumatic stress disorder (PTSD) as a

more severe PTSD symptoms. The study also

result of Typhoon Haiyan affected almost

used PTCI, a 33-item scale assessing nega-

half of the respondents of a recent study by

tive cognitions about self, negative cognitions

Moderno, Carpio, Nalipay and Saavedra.

about the world, and self-blame. Each item was

Entitled PTSDs underlying dimensions in

to be answered from 1 (completely disagree) to

Typhoon Haiyan survivors: Assessing Diagnos-

7 (completely agree). PTCI can distinguish be-

tic and Statistical Manual of Mental Disorders,

tween people who have or do not have PSTD.

Fifth Edition (DSM-5) symptomatology-based

The data gathered were screened and,

PTSD models and their relation to post-trau-

through expectation-maximization, randomly

matic cognition, the study is one of the few re-

missing values were attributed and substituted.

searches that have used the recently released

The data were analyzed using EQS 6.2 and fol-

DSM-5 models and is arguably the first DSM-

lowed procedures suggested by Byrne. Con-

5-based study on survivors of a devastating ty-

firmatory factor analysis (CFA) was used. The

phoon. The study also looked at the differential

authors permitted the correlation with all factors

relationships of specific post-traumatic cogni-

and the disallowed correlated errors. To modify

tions with PTSD symptom clusters based on

the fit statistics, robust maximum likelihood es-

the studys best fitted model. [Psychiatr Q 2016

timation method with mean-adjusted Satorra-

Feb 26. DOI 10.1007/s11126-016-9429-z. Epub

Bentler chi square was employed, and in as-

ahead of print]

sessing the models, conventional fit indices

The study involved 632 young adults who

were employed.

had a direct experience of Typhoon Haiyan. All

The authors named Model 6 as the best fit-

of them were also enrolled in a university in the

ting model, and multiple regression analyses

Philippines. Their mean age was 18.03 years

were done to analyze the uniqueness of its fac-

(SD=1.78), and the majority was female (79.9

tors. Post-traumatic cognitions served as pre-

percent).

dictors, while the seven Model 6 factors served

The study used PCLC-5, a 20-item self-report

as outcome variables. The authors discovered

scale that examined the gravity of PTSD symp-

that factors have different degrees of relation-

toms based on the symptoms specified in the

ships between them.

MAY 2016 P H I L I P P I N E FO C U S 14

Both dysphoric arousal and anxious arousal

Anhedonia was predicted only by negative

factors are foretold by negative self-cognitions

self-cognitions in contrast to negative affect,

and negative world-cognitions, but negative

which was shown to have significant relation-

self-cognitions are more strongly related to

ships with all post-traumatic cognition factors.

dysphoric arousal than anxious arousal, while

According to the authors, these results im-

negative world-cognitions are more strongly

ply that survivors dysfunctional cognitions,

related to anxious arousal than dysphoric

may it be a negative cognition about the self or

arousal. On the other hand, externalizing be-

the world, are likely to lead them to experience

havior factor was predicted only by negative

negative emotions. It is of significance to note,

self-cognitions.

however, that only negative self-cognitions af-

Negative affect was consistently predicted

fect the likelihood to experience (reduced)

by all three post-traumatic cognition compo-

positive emotions. The varying influences of

nents, while avoidance was predicted only

post-traumatic cognitions with positively- and

by negative self- and world-cognitions. Nega-

negatively-valenced affect add up to the call for

tive self-cognitions were associated more with

examining these constructs separately in rela-

negative affect than avoidance.

tion to the latent structure of PTSD.

Whats in an RxBox? Tools to save lives

DR JAMES A. SALISI

he Philippines has more than 1,500 rural

health clinics that cater to primary health

care needs of the people. Many of these clinics are in geographically isolated and disadvantaged areas in remote islands or mountain villages where they serve as the frontline
healthcare providers and often the only lifeline
for many people when they get sick.

the National Telehealth Center of the Univer-

In a bid to tackle the geographical barriers

sity of the Philippines Manila collaborated to

and help the frontline workers give quality care,

develop and implement the RxBox Research

the Department of Science and Technology,

Program.

Electrical and Electronics Engineering Institute

Indeed, the RxBox is not just a box but a re-

of the University of the Philippines Diliman and

search program that combines a biomedical

MAY 2016 P H I L I P P I N E FO C U S 15

device, an electronic medical record system

patients benefited

and telemedicine training to assist health work-

from remote car-

ers in giving life-saving services to people in

diology

(telecar-

remote and disadvantaged communities in the

diology)

consult.

Philippines.

A farmer in Nueva

The RxBox biomedical device consists of

Ecija

having

several monitoring devices and a tablet. Each

heart attack was di-

unit has a blood pressure monitor, a pulse oxim-

agnosed and man-

eter, an electrocardiogram (ECG), a fetal heart

aged on time with

monitor, a maternal tocometer and a tempera-

the help of the doc-

ture sensor. These sensors are connected to a

tor-to-the-barrio

tablet that displays, records and transmits sig-

at the rural health

nals coming from a patient using a well-estab-

clinic using RxBox

lished and open-source electronic health record

and the NTSP.

system for rural health clinics called Community

Health Information Tracking System or CHITS.

Cover of National Telehealth

Centers brochure on RxBox

Expectant mothers in Benguet are now experiencing a more efficient service during their

When it is connected to the Internet, an Rx-

prenatal consults at the rural health clinics

Box unit can be used as a telemedicine de-

where RxBox aids in health record-keeping and

vice that directly interfaces with the National

management in addition to assisting early de-

Telemedicine Service Program through which

tection of abnormalities such as preterm labor

a primary care physician or health worker can

and decreased fetal movement.

collaborate with specialists from the Philippine

General Hospital (PGH) in managing patients.

To date, 143 municipalities are part of the

RxBox program and 77 more have volunteered

Such is the power to improve health services

to participate. The project manager, Dr Kristine

of an RxBox that a record of an ECG tracing us-

Mae Magtubo, is anticipating the deployment

ing the device could be transmitted via email

of 1,000 units by the end of 2016 all over the

from anywhere in the Philippines and received

country through funding by the DOST and its

by a specialist at the PGH. The specialist could

regional offices and field implementation by the

give an expert opinion and advice on further

National Telehealth Center.

clinical management to a general practitioner in

a remote town in a more cost-effective way.

Were moving towards commercialization,

to support users who are coming off-grant and
also explore ways to provide the product and

Impact on communities

service to other markets, Magtubo said.

Several examples have been documented

Since it is primarily a research project,

demonstrating the usefulness of RxBox. In a ru-

the RxBox device is also undergoing clini-

ral clinic in an island in Pangasinan, two elderly

cal validation at the PGH. In addition, to en-

MAY 2016 P H I L I P P I N E F O C U S 16

sure that the device is up to standards, the

change the workflow and affect how things are

device is being tested rigorously with the help

done at the clinic. Changes are disruptive and

of the Department of Trade and Industry

could negatively affect the work environment;

Bureau of Product Standards.

that is why good change management is critical in ensuring smoother transitions.

Challenges

Leadership at the municipality where the

Although the development and implementa-

RxBox is used is important in maximizing the

tion of the entire program have shown prom-

benefits of the program. The support and trust

ising results, it is not without its own set of

of the community also affect the intention to

challenges. The introduction of RxBox could

use the technology according to Magtubo.

Vaccine refusal linked to higher risk

of measles and pertussis
ROSHINI CLAIRE ANTHONY

cent (n=199) occurred in vaccinated individuals. Of 970 cases with detailed vaccination in-

accine exemption is associated with an

formation, 574 cases were in individuals who

increased risk of measles and pertussis,

were age-eligible for the measles vaccine yet

a recent US study shows. To assess if vaccine

did not receive one, with 70.6 percent (n=405)

refusal, delay or exemption was linked to out-

of them unvaccinated due to nonmedical

breaks of measles and pertussis in the US,

reasons.

researchers looked for studies published be-

Among 32 pertussis outbreaks comprising

tween January 2000 (postmeasles elimination

10,609 cases in individuals aged between 10

era) and November 2015 for the measles co-

days and 87 years, 24-45 percent of the five

hort and from January 1977 to November 2015

largest outbreaks (Arizona in 1988, California

for the pertussis cohort. [JAMA 2016;315:1149-

in 2010 and 2014, Washington and Oregon

58]

in 2012) involved unvaccinated individuals.

There were 18 published studies on measles

In eight of 12 reports with data on reasons for

comprising 1,416 cases in individuals ranging

non- or undervaccination (fewer than recom-

from age 2 weeks to 84 years (178 cases in

mended doses), 59 to 93 percent were unvac-

individuals <12 months). Of these, 56.8 per-

cinated due to vaccine refusal.

cent (n=804) occurred in individuals with no

There were reports of pertussis epidemics

history of measles vaccination, while 14.1 per-

in communities with high vaccination rates, an

MAY 2016 P H I L I P P I N E F O C U S 17

occurrence study authors attributed to a de-

reasons for vaccine hesitancy among parents,

cline in immunity. However, there was still an

such as perception on risk of vaccine-pre-

association between vaccine refusal and per-

ventable diseases and safety of routine vac-

tussis risk in some communities, they said.

cination. This study builds up on data show-

The authors believe that enforcement of vac-

ing an association between vaccine refusal

cine mandates, be it at a school- or state-level,

and risk of varicella, pneumococcal disease,

as well as increasing the difficulty to acquire

measles, and pertussis. [Arch Pediatr Adolesc

exemption are crucial to raising vaccination

Med 2010;164:66-70; Vaccine 2011;29:994-9;

rates in the community. However, they also

JAMA 1999;282:47-53; JAMA 2006;296:1757-

highlighted the importance of acknowledging

63]

When medical devices are turned

into jail weapons
GABRIEL ANGELO SEMBRANO

arlier in 2016, authorities conducted

Oplan Galugad in various jails across

the country. In the biggest prison in the country,

the New Bilibid Prison, authorities seized various items including cellphones, extension wires
and bladed weapons. In the past, authorities
have also uncovered illegal drugs and firearms
apart from computers and home appliances
inside these prisons. In Naga City Jail, various
improvised weapons created from utensils and

oner bringing drugs inside by hiding it inside his

broken mirrors have been confiscated.

prosthetic leg.

Issues such as these are not new and are

In fact, even medical equipment things that

not unique to the Philippines. In Germany in the

have been created to preserve life are trans-

1980s, two inmates made a shotgun out of iron

formed into things that threaten life.

bedposts and lead from curtain tape and match

In 1995, Hayden, Laney and Kellerman em-

heads. Batteries and broken lightbulbs were

barked on a study to find out more about the

used to light it. Another case involved a pris-

incidences of modification of medical devices

MAY 2016 P H I L I P P I N E F O C U S 18

into weapons in penal institutions in three states

which is technically more open and less secure.

in the US. The study was pursued due to the

The procurement of health care outside the

case of a 27-year-old inmate who converted into

confines of detention facilities raises legitimate

a potentially lethal weapon a Velcro-type knee

concerns for the well-being of inmates and law

immobilizer that was given to him for the pur-

enforcement personnel alike, according to the

pose of treating a sustained knee sprain. The

authors.

authors became interested in determining how

Furthermore, medical workers may not be

rampant these kinds of cases are in their area.

conscious of the possible risks in the prescrip-

[Ann Emerg Med 1995;26:739-42]

tion of medicines and medical devices or equip-

Hayden et al approached all 81 detention

ment as these may be modified for illicit activity.

facilities in Tennessee, Arkansas, and Missis-

Medical equipment may also be stolen for such

sippi, and a total of 62 institutions responded,

purpose. Medical workers should therefore

including 25 state penitentiaries, 31 county jails,

keep these in mind.

1 state minimum-security facility, one state max-

Respondents identified the following con-

imum-security facility, one work-release center,

cerns for community health care providers in the

1 county detention center for drunken-driving

aspects of evaluation and treatment of incarcer-

offenders, and one federal penitentiary.

ated patients: identification of inmate patients

Out of these, 40 percent affirmed that stolen

and comprehension of the risks involved in their

or unauthorized medical equipment had been

treatment (19% of respondents), disregard for

found among inmates, and 34 percent affirmed

security concerns (19%), need for good com-

that medical equipment (whether prescribed or

munication between physicians and security

not) had been used or modified for illicit purpos-

personnel (12%), and caution about the types

es. Respondents noted both medication and

of medications prescribed and medical equip-

medical appliances used in such cases.

ment issued (29%).

The authors concluded that although au-

To address these issues, respondents rec-

thorities see the issue of incarcerated patients

ommended the following actions: (1) officers

creating weapons out of medical equipment

should stay with inmates at all times, (2) the

or devices as a valid security problem, health

restraints and weapons of officers are neces-

care workers attending to these patients at a

sary tools of their trade, (3) good communica-

periodic level do not really acknowledge it as

tion between physicians and officers is essen-

such.

tial, and (4) the emergency physician should

Hayden et al prescribed extra precautions

learn whether the equipment or drugs he or she

in dealing with incarcerated patients. Medical

is prescribing could be used by a prisoner to

workers are exposed to the risks that come with

hang, stab, poison or mutilate, and abuse of

transporting the incarcerated patient from the

standard medical therapies must be considered

detention facility into a medical facility outside

in the health care of prisoners.

MAY 2016 F E AT U R E 19

What is it like to be on the other side:

a diabetologists account as a person
with diabetes
Dr Amor Awayan, who is a consultant with the San Pablo Doctors Hospital in
San Pablo City, Laguna, shared her own struggle with type 1 diabetes during a
lay forum hosted by the Philippine Society of Endocrinology and Metabolism on
March 16, 2016 at EDSA Shangri-La Hotel in Mandaluyong City. She happens
to be an endocrinologist.
DR YVES SAINT JAMES AQUINO

t was in 1998 when the first symptoms began,

shared Awayan, who was a medical student

at the time at the University of Santo Tomas Faculty of Medicine and Surgery. She noticed she
was losing weight and had increased frequency
of urination with excessive thirst. It was only dur-

ing one of her classes in medical school did she

understand what these symptoms meant. She

time, and I was wondering why at such a young

was surprised to realize that what her profes-

age I was already having [diabetic] symptoms,

sor was discussing matched her diabetic symp-

she said.

toms, eg, polydipsia, polyuria, and weight loss.

After several blood tests, she found out she had
diabetes.

An unpleasant treatment
At the time, it was not clear whether she had

I was shocked, shared Awayan, who shared

type 1 or type 2 diabetes since her being 24

her story in Filipino. It seemed that the theo-

years old did not seem to fit the typical profile

retical knowledge of diabetes she just recently

for either type of diabetes. Her age made her

learned was becoming too real. She shared that

too old for type 1 diabetes, which usually in-

she was so distressed knowing that diabetes is

volves younger patients, but too young for type

associated with serious complications, includ-

2 diabetes.

ing stroke, heart attack, blindness, and kidney

complications that would require dialysis.
I was so afraid. I was only 24 years old at the

After suffering from constant fatigue in addition to other diabetes symptoms, she was
advised hospital admission. It was during this

MAY 2016 F E AT U R E 20

time that she experienced her first insulin injec-

She has since fully recovered. But even now

tion. It was such an unpleasant experience, ac-

that she tries to monitor what she eats, she ad-

cording to Awayan. My blood sugar crashed. I

mitted it is easier said than done.

was shivering, sweating excessively, and had a

headache, she recounted.

Most of the time I get invited for talks or

meetings, and its hard to resist some types

Additional tests showed that Awayans urine

of food like lechon, fried chicken or chocolate

had ketones, which are commonly seen in type

cake, she shared. This is why I salute diabetic

1 diabetes. With type 1 diabetes, there is total

patients who can control themselves. As a doc-

absence of insulin, and without insulin the cells

tor, I do have a difficult time.

in the body cannot absorb sugar to produce en-

Awayan claimed that she also had prob-

ergy. The absence of insulin forces the body to

lems committing to regular exercise after hav-

use fat for energy instead of glucose, and the

ing knee injury and having suffered a herniated

metabolism of fat leads to production of ketones

disc. She explained that, at present, brisk walk-

that are excreted in the urine. This is in contrast

ing during hospital rounds has become her

with type 2 diabetes where the body either has

form of exercise.

little insulin or cannot use insulin properly.

I was only 24 years old, and I was studying

Through their eyes

medicine to become a doctor. I thought all doc-

Awayan shared that she dislikes other phy-

tors should be healthy, that they are not sup-

sicians who would easily lash out on patients

posed to have any sickness, said Awayan, feel-

who do not comply with a particular diabetic

ing frustrated upon learning that type 1 diabetes

regimen. As a patient herself, she knows there

meant a lifetime use of insulin injection.

are situations when she could not find the time

to check her blood glucose, inject herself with

At a high cost

insulin, exercise regularly, or follow a strict diet.

Awayan would soon experience the full ex-

Instead of reprimanding her patients, she

tent of having diabetes. The issue was not only

said that she would try to find a way to motivate

medical, and it was not just about suffering some

her patients by talking about her experience,

of the debilitating symptoms. She cited several

acknowledging the difficult aspects of diabetic

difficulties including high cost of medication,

management that she has also faced. And giv-

finding time to measure her blood glucose, in-

en her first-hand knowledge, she emphasized

jecting herself with insulin, and following a strict

the importance of family supportbe it physi-

diabetes-appropriate dietary regimen.

cally, emotionally or financially.

She shared that in 1992, she became too

Accepting what I have, and imparting to [pa-

complacent with her diet that it led to a serious

tients] what I have learned, I believe, would help

complication: a transient ischemic attack. She

make a difference. For in the end, theres always

was only 28 years old at that time.

life after diabetes, concluded Awayan.

MAY 2016 M A R K E T WATC H 21

Exhibit highlights benefits of PCHRD breakthrough technologies

and services

his years (2016) anniversary exhibit of the Philippine Council for Health Research and Development

(PCHRD) highlighted its breakthrough technologies and

services. Among the technologies featured during the
Councils 34th anniversary celebration were eHATID, Rx-

Box, Axis Knee System and Biotek-M. Benefits of PCHRD

services namely Dengue Vector Surveillance Website, Philippine Traditional Knowledge Digital Library (TKDL), Philippine Drug Discovery and Development (DDD) Program, and Philippine Health Research Registry
(PHRR) were also showcased.
The eHATID provides decision-making support to LGUs as it delivers real time health information even without internet connection. The RxBox reduces unnecessary travels and hospitalizations as it enables management of patients from geographically isolated areas. The Axis Knee
System allows access to inexpensive knee replacement, while the Biotek-M Dengue Detection Kit
is as accurate yet less costly as the currently available Polymerase Chain Reaction (PCR) technology. The DDD Program develops alternative drugs that are safe, effective, accessible, and affordable while PHRR allows researchers to input and update data entries by themselves.

Expert Moms recommend Virlix (cetirizine) and Ambrolex

(ambroxol) this summer

xpert Moms discussed coughing and al-

Led by celebrity and Expert Mom Rica

lergy, and the ways they can be manged,

Peralejo, the campaign seeks to educate moth-

during the launch of GSK Expert Mom cam-

ers on how to correctly and promptly address

paign on March 30, 2016 at the Makati Shangri-

cough and allergies for the entire family.

La Hotel. For productive cough, doctors can

As a mom, I want to make sure that summer

recommend protussives such as Ambrolex,

would become a memorable time for the whole

which has a blackcurrant flavor that kids will

family... Im very happy to be part of the Expert

love. It comes in thrice-daily tablet and once-

Moms campaign because I think its exciting

daily capsule formats for adults. When allergy

to meet other moms who are keen on keeping

happens, Virlix can be used to help manage

themselves healthy in order to take care of their

symptoms.

families, said Peralejo.

MAY 2016 M A R K E T WATC H 22

SLMC-Global City performs PHs first robotic lung resection

team of thoracic surgeons from St. Lukes Medical Center

(SLMC)-Global City has recently performed the countrys

first robotic lung resection on a 61-year-old female patient who

was discovered to have a 3.5cm mass in the left upper lobe of
her lungs.
The mass was suspected to be malignant following work-up.
Using the third-generation Da Vinci surgical system, the team performed a resection of the left upper lobe of the lung with complete
mediastinal lymph node dissection. After the surgery, the patient had a fast recovery and minimal
postoperative pain.
The team was headed by Dr Edmund E. Villaroman, and assisted by Drs Karlos R. Aleta
and Mariam Grace A. Delima. The surgeons are pioneers in advanced minimally invasive thoracic
surgery in the country.

Montoya leads PCHRD 34th anniversary

celebration

r Jaime Montoya, Philippine Council for Health Research

and Development (PCHRD) executive director, led the

Councils 34th anniversary celebration on March 17, 2016 at the

New World Makati Hotel.
The celebration focused on the globalization of research and innovation for health and the
growing interest for international research collaborations. According to Montoya, passing the
recent external audit of Quality Management System (QMS) of the Council is just one proof their
systems are geared towards client satisfaction.
He thanked the commitment and collaboration of their local and global partners such as
the Department of Health, Commission on Higher Education, Regional Health Research and
Development Consortia Philippine Biomedical Device Innovation Consortium, UK Medical Research Council, Institut Pasteur, ASEAN-NDI, Western Pacific Index Medicus, Asia Pacific Association of Medical Journal Editors, and Council on Health Research for Development. The
partnerships led to the success of the Global Forum on Research and Innovation for Health
(Forum 2015) which generated new and significant health partnerships fostering researches and
innovation.

MAY 2016 M A R K E T WATC H 23

PHA initiates CPR-Ready Philippines

Awareness Campaign

he Samboy Lim Bill, an act implementing mandatory

CPR training in the school curriculum of high school, is

already on final 3rd Reading in Senate on May 2016. Hopefully with its successful passage, it will ultimately pave the
way for making the youth the future lifesavers and eventually will give an opportunity for them to cascade it to the community.
To fully jumpstart the awareness of the importance of CPR in line with the much awaited successful passage of the bill, the Philippine Heart Association (PHA) initiated the Mass CPR Nationwide campaign on April 25, 2016, in cooperation with The Expanded Council of PHA on CPR,
Department of Health, Philippine Red Cross, and American Heart Association Asia Pacific Training
providers. The main goal of the activity was to gather target participants (all Filipinos ages 8 to 60
years old) as many as possible to do hands-only CPR on specified CPR sites on all regions of the
Philippines from Luzon, Visayas and Mindanao on a given time on one specified date.

PhilHealth reinstates PMA Certificate of Good Standing

Requirement for accreditation

he Philippine Health Insurance Corporation (PhilHealth) has restored the Cer-

tificate of Good Standing (CGS) from the

Philippine Medical Association (PMA), as a requirement for PhilHealth accreditation for doctors starting January 8, 2016. This new ruling
is contained in the PhilHealth Circular #2015037 dated December 8, 2015. A revised CGS
from the component medical society is required
for securing the PMA CGS.
The CGS was previously excluded as a requirement for accreditation in 2013 as stated in rules and regulations. However, the PhilHealth
recognized that being in good standing with the PMA and the Philippine Hospital Association (PHA), would increase the probability of healthcare providers to comply with the Code of
Ethics of their respective organizations.


Department of Medicine & Therapeutics
Faculty of Medicine
The Chinese University of Hong Kong

Hong Kong Convention and Exhibition Centre

Programme highlights
Respiratory Medicine: COPD Exacerbation Prevention, Advances in
Interventional Pulmonology, Management of Obstructive Sleep Apnoea
Improving Cardiovascular Outcomes in T2DM
Diabetes in Older People
Cardiovascular Medicine: NOAC for Stroke Prevention, Vasodilating
Beta-blockers in Hypertension, Angiotensin Receptor-Neprilysin Inhibition
in Heart Failure
Update on Acute Kidney Injury
Update on the Assessment and Treatment of Arthritis
Advances in Treatment of Psoriasis
Challenges of Epidemics: Zika Virus, HIV, Norovirus Gastroenteritis
The Improving Outlook of Brain Disorders: Parkinson's Disease, Seizure
Disorders, Multiple Sclerosis
Update in Gastroenterology: CRC Screening, Treatment Update in H. pylori
Infection, Clostridium Difficile Infection
Advances in the Management of Bleeding and Thrombosis
Food and Health
Scientific Challenges in Translational Medicine

Register at
www.mect.cuhk.edu.hk/AIM
Contact us

Tel :

(852) 2632 1299

Department of Medicine & Therapeutics

Fax :

(852) 2637 3852

The Chinese University of Hong Kong

Email : aim@cuhk.edu.hk

MAY 2016 CO N F E R E N C E COV E R AG E 24

65th Annual Scientific Sessions of the American College of Cardiology (ACC)

2016, April 2-4, Chicago, Illinois, US

HOPE-3 supports statins with

or without BP drugs for reducing
CV events
RADHA CHITALE

esults from a trio of papers detailing the

Heart Outcomes Prevention Evaluation

(HOPE)-3 trial demonstrated that cholesterollowering statin therapy plus two blood pressure
drugs reduced the risk of cardiovascular events
in intermediate-risk patients with average cholesterol and blood pressure levels.
However, the blood pressure treatments

hypertensives if you also lower cholesterol

simultaneously.

were only beneficial for hypertensive patients,

HOPE-3 was a 2x2 factorial design trial that

calling into question the polypill concept for pri-

included 12,705 people at intermediate risk

mary prevention.

without cardiovascular disease randomized to

The implications for practice are huge

rosuvastatin or placebo and an angiotensin re-

I think we certainly should consider using

ceptor blocker (ARB) plus a thiazide diuretic or

statins much more widely than we have used

placebo. [N Engl J Med 2016;doi:10.1056/NEJ-

them thus far, said co-investigator Dr. Salim

Moa1600177]

Yusuf, professor of medicine at McMaster Uni-

The first co-primary outcome of a composite

versity and executive director of the Popula-

of heart attack, stroke, and death from cardiovas-

tion Health Research Institute of McMaster

cular disease occurred in 3.6 percent of patients

University and Hamilton Health Sciences in

in the combined therapy group compared with

Hamilton, Ontario, Canada during a presen-

5 percent in the placebo group after a median

tation at the recent ACC 2016 Scientific Ses-

5.6 years of follow up (hazard ratio [HR], 0.71,

sion.

95 percent confidence interval [CI], 0.56 - 0.90;

In particular for patients with hyperten-

p=0.005).

sion, our study suggests you can essen-

The second co-primary outcome, which add-

tially double the benefit of lowering [BP] in

ed heart failure, cardiac arrest, or revasculariza-

MAY 2016 CO N F E R E N C E COV E R AG E 25

tion to the first co-primary outcome, occurred

associate professor of rehabilitation science

in 4.3 percent of combined therapy group and

at McMaster University and director of the pre-

5.9 percent of the placebo group (HR, 0.72, 95

vention program at the Population Health Re-

percent CI, 0.57 - 0.89; p=0.003).

search Institute, who led the rosuvastatin arm

The relative risk reduction was 30 percent

of HOPE-3.

overall for the combined therapy group, 40 percent among hypertensive patients, and 20 percent among nonhypertensive patients.

BP lowering useful in hypertensive patients

A separate analysis focused on blood pres-

Though not wanting to minimize the trial

sure lowering showed no significant benefits

results, Dr. Valentin Fuster, director of Mount Si-

from treatment compared to placebo, except in

nai Heart at The Mount Sinai Hospital in New

patients whose blood pressure was over 143.5

York, New York, US, who was unaffiliated with

mm Hg at baseline (about one-third of partici-

the trial, emphasized care in interpreting the re-

pants). In this group, 4.8 and 5.7 percent of pa-

sults, since a 30 percent risk reduction is one

tients experienced the first and second co-pri-

way of describing results where the absolute

mary endpoints, respectively, compared to 6.5

event rate was about 1.2 percent.

and 7.5 percent experienced by those receiving

placebo. [N Engl J Med 2016;doi:10.1056/NEJ-

Statins alone lowered CV events

Moa1600175]

An analysis of statin use showed that 3.7 per-

These data suggest blood pressure low-

cent of patients on rosuvastatin experienced the

ering medications are appropriate for people

first co-primary endpoint vs 4.8 percent of pa-

with hypertension but that people with lower

tients on placebo (HR, 0.76, 95 [CI], 0.64 - 0.91;

blood pressure who have no other reasons

p=0.002). The second co-primary endpoint sim-

to use blood pressure reducing drugs should

ilarly favoured the statin group 4.4 percent oc-

avoid [them], said Dr. Eva Lonn, a cardiolo-

currence versus 5.7 percent in the placebo group

gist and professor of cardiology at McMaster

(HR, 0.75, 95 percent CI, 0.64 - 0.88; p<0.001),

University and senior scientist at the Popula-

and after a year patients on statin therapy had a

tion Health Research Institute, who led the

25 percent reduction in LDL cholesterol. [N Engl

blood pressure portion of HOPE-3, adding that

J Med 2016;doi:10.1056/NEJMoa1600176]

in the lowest blood pressure tertile, there was

The take-home message is that statins are

a tendency towards harm with treatment.

safe and effective, and that because benefits

were similar irrespective of pre-treatment cho-

Putting the polypill in play?

lesterol levels or levels of inflammatory mark-

In what was the first formal testing of the

ers, no baseline blood tests are required to

polypill concept on clinical events, Yusuf said,

identify the patients who will derive benefits

the conclusion from HOPE-3 is that the con-

from this treatment, said Dr. Jackie Bosch,

cept is valid in people with elevated BP. In oth-

MAY 2016 CO N F E R E N C E COV E R AG E 26

ers, there is no benefit.

rather than an approach that is based primarily

In an accompanying comment, Dr. William

on LDL cholesterol levels, and the results add to

Cushman of the University of Colorado, Den-

the evidence supporting statin use for primary

ver, in Denver, Colorado, US, and Dr. David Goff

prevention. [N Engl J Med 2016;doi:10.1056/

of the University of Tennessee Health Science

NEJMe1603504]

Center in Memphis, Tennessee, US wrote in favor of statins for primary prevention.

They also noted that a higher dose of antihypertensives may have further reduced

These results support a risk-based ap-

the risk of cardiovascular events, but Lonn

proach to statin use, which has been recom-

said that in their population of mostly aver-

mended in recent [American College of Cardi-

age blood pressure, avoiding side effects was

ology/American Heart Association] guidelines,

more important.

Women have greater heart disease

risk despite similar symptoms as men
PEARL TOH

omen have more cardiac risk factors than

men, yet are more likely to be catego-

rized as being at lower risk based on standard

scoring test for cardiovascular risk, according
to the PROMISE* study presented at the 65th
American College of Cardiology (ACC) meeting. This highlights the need for sex-specific approaches to the diagnosis of heart disease.
Compared with men, women with suspected
coronary artery disease (CAD) were more likely
to be older (mean age 59.0 versus 62.4 years),

Additionally, these women were more likely

have high cholesterol, hypertension, and a fam-

than men to have unconventional risk factors

ily history of stroke (all p<0.005), while less like-

such as sedentary lifestyle and depression

ly to be overweight and to smoke (p<0.001).

(p<0.001), which were excluded from most

[JACC Cardiovasc Imaging 2016;doi:10.1016/j.

standard cardiovascular risk-assessment ques-

jcmg.2016.02.001]

tionnaires.

MAY 2016 CO N F E R E N C E COV E R AG E 27

Despite having greater risk factors, women

in Durham, North Carolina, US.

were more often regarded as being at lower

Providers also need to know that, in the

risk of CAD based on cardiac risk-assessment

vast majority of cases, women and men with

scores before undergoing any diagnostic tests

suspected heart disease have the same symp-

(34.1 vs 40.7 percent; p<0.001), and less likely

toms, said Hemal, highlighting that shortness

to test positive by imaging (9.7 vs 15.1 percent;

of breath and chest pain were the primary

p<0.001) despite being more often referred for

symptoms found in both men and women with

imaging tests than men.

suspected CAD, in contrast to previous belief.

[The study] has provided insights into

The PROMISE study randomized 10,003

sex-specific factors that are uniquely impor-

patients to anatomic cardiac test by heart com-

tant in the noninvasive diagnosis of myo-

puterized tomography (CT) scan or functional

cardial ischaemic syndromes in women,

stress tests such as exercise electrocardiogram

said Dr. Robert Bonow from the Northwest-

or stress echocardiography. The study evalu-

ern University Feinberg School of Medicine

ated the differences in diagnostic process but

in Chicago, Illinois, US, and co-author Dr.

not the prognosis and outcomes between men

Jennifer Mieres in a related commentary.

and women, which Hemal said was a study

Due to the perceived lower risk, there were

limitation.

growing concerns that women were less like-

The most important take-home message for

ly to receive intensive CAD management than

women from this study is that their risk factors

men, said Bonow and Mieres.

for heart disease are different from mens, but in

For healthcare providers, this study shows

most cases symptoms of possible blockages in

the importance of taking into account the dif-

the hearts arteries are the same as those seen

ferences between women and men through-

in men, said Hemal.

out the entire diagnostic process for suspected

heart disease, said study lead author Kshipra

*PROMISE: Prospective Multicenter Imaging Study for Evaluation

Hemal from the Duke Clinical Research Institute

of Chest Pain

MAY 2016 CO N F E R E N C E COV E R AG E 28

65th Annual Scientific Sessions of the American College of Cardiology (ACC)

2016, April 2-4, Chicago, Illinois, US

TAVR noninferior to surgery in aortic

stenosis
RADHA CHITALE

ata from the noninferiority PARTNER* 2A

trial comparing transcathether aortic valve

replacement (TAVR) to more invasive open

heart valve replacement surgery in intermediaterisk patients with severe aortic stenosis after 2
years showed similar efficacy and safety results
as well as reduced hospital stays and fewer of
some major complications in the TAVR group.
At 2 years, rates of all-cause death or dis-

director of the Center for Interventional Vascular

abling strokes, the primary endpoints, were

Therapy at Columbia University Medical Center-

19.3 percent for TAVR and 21.1 percent for sur-

New York Presbyterian Hospital in New York,

gery (hazard ratio [HR] in the TAVR group, 0.89,

New York, US and co-principal investigator of

95 percent confidence interval [CI], 0.73-1.09;

the PARTNER trials.

p=0.25; p=0.001 for noninferiority). [N Engl J

Med 2016;doi:10.1056/NEJMoa1514616]

We know surgery is good, but it is still a

major procedure and for many patients, a less-

The rate of primary outcome events were

invasive approach may be the preferred alter-

even better among TAVR patients who received

native. As we continue to evolve the procedure

transfemoral TAVR (76 percent) via a groin cath-

and technology, its important to know whether

eter compared to the rest, who received slightly

TAVR is an effective alternative in these lower

more invasive transthoracic TAVR via a catheter

risk patients.

through the chest wall 16.8 and 20.4 percent,

PARTNER 2A included 2,032 patients ran-

respectively (HR, 0.79, 95 percent CI, 0.62-

domized to TAVR (n=1,011) with the SAPI-

1.00;p=0.05).

EN XT valve or standard open heart surgery

The 2-year follow-up allows enough time to

accurately assess the relative performance of

(n=1,021) between December 2011 and

November 2013.

these two valve replacement therapies, said

While the rate of primary endpoint events re-

Dr. Martin B. Leon, professor of medicine and

mained consistent in favour of TAVR, secondary

MAY 2016 CO N F E R E N C E COV E R AG E 29

endpoints differed between the groups. TAVR

XT device, made

patients spent less time in the hospital com-

by Edwards Life-

pared with surgery patients (2 vs 4 days in the

sciences,

who

ICU and 6 vs 9 days of hospitalization, respec-

supported

the

tively), had improved aortic valve areas, lower

PARTNER trials,

rates of acute kidney injury, severe bleeding

is out of date at

events, and new onset atrial fibrillation.

this point com-

But TAVR patients did have more ma-

pared to newer

jor vascular complications than the surgery

generation valve

group, as well as more paravalvular regurgi-

implants. This might dilute the relevancy of the

tation, which was expected considering the

findings, he said, but it could also underscore

valves are not sewn in place, said Dr. Craig

the benefits of a transcatheter valve implantation

Smith, chair of the Department of Surgery at

approach even with an older device.

Dr. Craig Smith

Columbia University in New York, New York,

In an accompanying comment, Dr. Neil E.

US and another co-primary investigator, but

Moat, a consultant cardiac surgeon at The Roy-

did not appear to be a problem in the long run

al Brompton Hospital in London, United King-

for the study group, given the primary event

dom, said new TAVR devices with lower-profile

outcomes.

delivery systems have increased the proportion

Despite the favourable results, TAVR is still

of patients who can be treated with a transfem-

not appropriate for many aortic stenosis patient.

oral approach and have significantly reduced

PARTNER 2a is part of the PARTNER group of

the incidence of moderate or severe paraval-

trials comparing TAVR to surgery. The current

vular leak. [N Engl J Med 2016;doi:10.1056/

study represents a group of patients with the

NEJMe1603473]

lowest risk yet, however, they are still among

Further trials on these newer generation de-

the highest-risk quintile of patients with aortic

vices in lower risk cohorts are awaited with

stenosis who are candidates for surgery in the

interest, he added.

United States, the researchers said.

Smith also acknowledged that the SAPIEN

*PARTNER: The Placement of Aortic Transcatheter Valve Trial

MAY 2016 CO N F E R E N C E COV E R AG E 30

65th Annual Scientific Session of the American College of Cardiology (ACC)

2016, April 2-4, Chicago, Illinois, US

Breast arterial calcification on

mammogram can unmask
atherosclerotic CVD risk
ELVIRA MANZANO

reast arterial calcification (BAC) on digital

mammogram appeared to be a better pre-

dictor of coronary arterial calcification (CAC) in

women than standard cardiovascular risk factors in a new study presented at the ACC meeting in Chicago, Illinois, US.
The message is if a woman is getting a
mammogram, look for BAC, said principal author Dr. Harvey Hecht, director of cardiovascu-

nary arteries often a signal for coronary artery

lar imaging at Mount Sinai St. Lukes Hospital in

disease (CAD). The likelihood of calcification

New York, US. The more BAC a woman has, the

increased with age, high blood pressure and

more likely she is to have calcium in her hearts

chronic kidney disease (CKD). Having BAC cor-

arteries. [ACC 2016, abstract 16-A-9366]

rectly identified women with atherosclerosis 63

Hechts co-author Dr. Laurie Margolies, as-

percent of the time.

sociate professor of medicine at Mount Sinais

Currently, there is no consensus on using

Icahn School of Medicine in Manhattan, US, said

CAC as a screening test and primary care physi-

what was remarkable was the very few false

cians only run extensive tests on patients when

positives for calcification. Mammography was

there is evidence of hypertension or a history

70 percent accurate at identifying women with

of heart disease. Our data show that mammo-

atherosclerotic cardiovascular disease (CVD).

gram is a more accurate detector of heart dis-

The study involved 292 women aged 60 or

ease than other well-established cardiovascular

younger who had digital mammography and

indicators such as high cholesterol, high blood

CT scans of the chest within a year. Seventy

pressure and diabetes, said Margolies.

percent of the women with calcification in the

BAC was noted in 124 or 42.5 percent of pa-

breast arteries also had calcification in the coro-

tients and was associated with increasing age

MAY 2016 CO N F E R E N C E COV E R AG E 31

(p<0.0001). The sensitivity and specificity of

risk women to be referred for standard CAC

BAC >0 for CAC >0 were 63 and 76 percent,

scoring and for clinicians to start focusing on

respectively, while positive and negative predic-

prevention, said Hecht. Women, particularly

tive values were 69 and 70 percent, respectively.

those aged 40-75 years who are the target of

There is a strong quantitative association

screening mammogram every 2 years, could

between BAC and CAC... BAC appeared to be

be ideal candidates for atherosclerotic CVD

equivalent to both the Framingham Risk Score

risk assessment.

[FRS] and the 2013 Cholesterol Guidelines

In an accompanying editorial, Drs. Khur-

Pooled Cohort Equations [PCE] for identify-

ram Nassir and John McEvoy from the Center

ing high-risk women, said Margolies. When

for Healthcare Advancement and Outcomes

women with established CAD were included,

at Baptist Health South Florida in Florida, US

BAC>0 was significantly additive to both FRS

said the findings support BAC documentation

[p=0.02] and PCE [p=0.04] for high-risk CAC.

in mammography reports. Whether the best

Multivariate analysis showed that early signs

use of BAC is to trigger additional testing or to

of plaque build-up in the coronary arteries were

directly inform preventive treatment decisions

most strongly related to BAC. While CAC was

by flagging high-risk women or reclassifying

twice as likely with advancing age or high blood

traditional heart disease risk estimate is wor-

pressure, it was thrice more likely with BAC.

thy of further discussion. [J Am Coll Cardiol

Using this information would allow at-

2016; doi:10.1016/j.jcmg.2015.09.017]

Losmapimod reduces inflammation

but not CV events in acute MI
ROSHINI CLAIRE ANTHONY

osmapimod, a p38 mitogen-activated protein kinase (MAPK) inhibitor, does not re-

duce the risk of major cardiovascular (CV)

events in patients with acute myocardial infarction (MI), according to results of the LATITUDETIMI 60* trial presented at the American College
of Cardiologys 65th Annual Scientific Sessions
in Chicago, Illinois, US.

MAY 2016 CO N F E R E N C E COV E R AG E 32

To assess the safety and efficacy of losmapi-

with acute MI for 12 weeks, losmapimod re-

mod on CV outcomes, researchers of this multi-

duced inflammation as measured by hs-CRP,

national, double-blind, phase III trial randomized

blunting the acute inflammatory response to MI

patients aged 35 years who had been hospital-

and reducing chronic inflammation. However,

ized with acute MI to receive losmapimod (7.5

losmapimod did not reduce the rate of recurrent

mg twice daily; n=1,738) or placebo (n=1,765)

major CV events, said Dr. Michelle ODonoghue,

for 12 weeks, with another 12-week follow-up

Associate Physician at Brigham and Womens

period.

Hospital, Boston, Massachusetts, US and one

One hundred and thirty nine (8.1 percent)

patients on losmapimod and 123 (7 percent)

of the investigators of the LATITUDE-TIMI 60

trial, who presented the trial findings.

patients on placebo experienced CV death, MI,

Based on a previous study which demonstrat-

or severe recurrent ischaemia requiring urgent

ed a lower, nonsignificant incidence of death,

revascularization (primary outcome) during the

MI, recurrent ischaemia, stroke and heart failure

12-week study period (hazard ratio [HR], 1.16,

in MI patients treated with losmapimod [Lancet

95 percent CI, 0.91-1.47; p=0.24). The primary

2014;384:1187-1195], researchers hypothesized

outcome incidence was similar at the 24-week

that losmapimod could potentially mitigate sev-

mark (10.3 vs 9.7 percent; HR, 1.11, 95 per-

eral complications in patients with acute MI.

cent CI, 0.9-1.38). [JAMA 2016;doi:10.1001/

jama.2016.3609]

This trial was an initial assessment of safety and efficacy of losmapimod and involved a

Compared to placebo, losmapimod reduced

smaller group (n=3,503). Upon completion, a

the levels of the inflammatory biomarker high-

larger trial involving a cohort of approximately

sensitivity C-reactive protein (hs-CRP; ratio of

22,000 patients was planned with efficacy as

means, 0.76, 95 percent CI, 0.62-0.91; p=0.004

the primary endpoint.

at 4 weeks and 0.73, 95 percent CI, 0.61-0.87;

p<0.001 at 12 weeks).

The authors believed that the results did not

justify proceeding to a larger efficacy trial in the

Serious adverse events were reported in

existing patient population. However, the trial

16 and 14.2 percent of patients treated with

yielded exploratory findings in ST-segment el-

losmapimod and placebo, respectively, while

evation MI (STEMI) which were worthy of further

permanent premature drug discontinuation

investigation, said ODonoghue.

due to adverse events occurred in 4.4 and 3.9

percent of the treatment and placebo groups,

*LATITUDE-TIMI 60: LosmApimod To Inhibit p38 MAP kinase as a

respectively.

TherapeUtic target and moDify outcomes after an acute coronary

When administered in a broad population

syndromE

MAY 2016 CO N F E R E N C E COV E R AG E 33

Morphine blunts antiplatelet

response in acute MI
ELVIRA MANZANO

orphine weakens antiplatelet response

among patients with ST-elevation myo-

cardial infarction (STEMI) undergoing primary

percutaneous coronary intervention (PCI) to restore blood flow to the heart.
This was the key finding from a study presented at the recent ACC 2016 Scientific Session.
Patients treated with morphine had worse
measures of platelet activity within an hour of
receiving a loading dose of aspirin plus ticagre-

pirin 300 mg and clopidogrel 600 mg while the

lor (Brilinta, AstraZeneca) or clopidogrel. [ACC

rest received ticagrelor 180 mg. Within 30 to 60

2016, abstract 1105-113]

minutes, blood tests were done to determine

Morphine has been widely used to alleviate

occlusion time and lysis time.

chest pain and anxiety of patients suffering from

Compared with the patients who had not re-

an acute MI, said study author Dr. Manivannan

ceived opiates, those who had received mor-

Srinivasan from the East and North Hertford-

phine had a shorter mean occlusion time (358

shire NHS Trust in the UK. But the drug can

s vs 670 s;p<0.001) and a longer median lysis

also delay gastric emptying and reduce the ab-

time (1392 s vs 1184 s;p=0.006).

sorption of other oral medications.

Srinivasan and team examined 125 consecutive patients (mean age 66; 93 percent male)

However, by day 2, the two groups had similar occlusion times (485 s vs 552 s) and lysis
times (1322 s vs 1184 s).

with acute STEMI who were scheduled to un-

The study was not powered to determine

dergo emergency primary PCI. Of these, 101

hard safety endpoints, but there was a non-

patients (81 percent) had received morphine in

significant trend to greater in-hospital adverse

ambulance enroute to the hospital. About half

events in the 101 patients who had received

had hypertension, 42 were smokers, and 16

morphine vs the other 24 patients (1 vs 0 death,

percent had type 2 diabetes (T2D).

1 vs 0 MI, and 2 vs 0 stroke).

Once in the catheterization laboratory, 102

Whether this [morphine] affects recurrent

patients were each given a loading dose of as-

early thrombosis risk and whether nonopi-

MAY 2016 CO N F E R E N C E COV E R AG E 34

ate analgesia may proffer advantages in this

other intravenous medication if morphine treat-

setting require further assessment, said the

ment is to be used, said Srinivasan.

researchers.

There are other alternatives that we can ex-

Large clinical trials are warranted to confirm

plore, such as nonopioid medication such as

the finding and to determine how this effect

IV paracetamol, he noted. Once morphine is

on platelets translates into patient outcomes.

given, we may consider giving other IV agents

Until then, caution should be exercised in the

that bypass the gastric emptying, such as GP

use of IV morphine and consideration given to

IIb/IIIa inhibitors or bivalirudin.

Excessive daytime sleepiness, long

naps tied to increased diabetes risk
ELVIRA MANZANO

ong naps and excessive sleepiness during the day may increase a persons risk

of developing metabolic syndrome, a cluster of

factors that are known to increase the risks of
diabetes, heart disease and stroke, according
to a meta-analysis presented at the recent ACC
meeting in Chicago, Illinois, US.
Excessive daytime sleepiness and lon-

a new strategy of treatment, said lead author

ger naps (>60 min/day) each significantly in-

Dr. Tomohide Yamada, a diabetologist from the

creased the risk of type 2 diabetes (T2D) by

University of Tokyo in Tokyo, Japan.

about 50 percent versus the absence of these

Yamada and his team analysed data from 21

factors in this meta-analysis using the restricted

studies involving 307,237 individuals from Asia

cubic spline model. By contrast, a shorter nap

and the West who were asked about their nap-

time (<60 min/day) did not increase the risk of

ping habits and daytime sleepiness. Questions

diabetes (p=0.07). [ACC 2016, abstract 16-A-

included Do you have a problem with sleepi-

13976)

ness during the day? and Do you sleep dur-

Given that metabolic disease has been in-

ing the day? among others. Responses were

creasing globally, clarifying the relationship be-

compared with theirhistory of metabolic syn-

tween naps and metabolic disease might offer

drome, T2D, and obesity.

MAY 2016 CO N F E R E N C E COV E R AG E 35

A dose-response meta-analysis showed a J-

was tied to an 82 percent increased risk of car-

shaped relationship between nap time and the

diovascular disease (CVD) and a 27 percent

risk of diabetes or metabolic disease. There was

increased risk of death from all causes. [Sleep

no increase in the risk of metabolic syndrome in

2015, in press) A separate study also by his

individuals who napped <40 min/day. In fact,

team and reported in September 2015 dem-

those who napped for <30 min/day had a slight

onstrated a 56 percent higher risk of diabetes

decrease in risk.

among fatigued individuals and a 46 percent

However, there was a sharp increase in risk

higher risk among those napping longer than

among those who napped >40 min/day or lon-

an hour. Shorter naps of less than an hour did

ger. For example, napping for >90 min/day in-

not raise any red flag, though.

creased the risk of metabolic syndrome by as

Sleep is important for a healthy lifestyle, as

much as 50 percent, as did excessive daytime

are diet and exercise. The US National Sleep

sleepiness.

Foundation recommends a 20-to 30-minute

In addition, napping for >60 min/day or be-

nap time to boost mental alertness. Short

ing overlytired during the day were both linked

naps may be beneficial for our health, but what

to a 50 percent higher risk for T2D. The study,

is not known are the mechanisms by which

however, was not designed to show the relation-

short naps work, said Yamada.

ship between time spent napping and obesity,

More studies are therefore warranted to un-

despite the close links between obesity and dia-

derstand how an individuals sleep habits can

betes or metabolic syndrome.

influence metabolic syndrome and CVD and

The results build on earlier findings by Yamadas team that napping longer than an hour

whether a patients nap habits can be used by

clinicians to predict other health problems.

Rate and rhythm control show similar

outcomes in postop AF
KAVITHA G. SHEKAR

ost cardiac surgery atrial fibrillation (AF) rate

control and rhythm control strategies yield

acceptable outcomes in stable cardiac patients,

reports an expert at the 65th ACC conference.
Despite the importance of postoperative AF,

MAY 2016 CO N F E R E N C E COV E R AG E 36

the most effective management strategy for this

control group 60 days post surgery. AF-free

common surgical complication remains uncer-

discharge was reported in 84.2 and 86.9 per-

tain, a factor that had led to a substantial variation

cent of the patients, respectively.

in treatment, said lead author Dr. Marc Gillinov,

We have shown that postoperative AF will

Department of Thoracic and Cardiovascular Sur-

resolve in more than 90 percent of the pa-

gery, Cleveland Clinic, Cleveland, Ohio, US. This

tients who are treated with either rate control

study was conceived with the intention of deter-

or rhythm control, said Gillinov. Patients and

mining the risk and benefit of rate versus rhythm

physicians now have the option to choose the

control to aid clinical management of post surgi-

strategy thats best for each individual patient.

cal AF.

The trial recruited 2,109 patients from 23 sites

The hospitalization duration from randomiza-

in the US and Canada from May 2014 to 2015.

tion to 60 days post surgery (primary outcome)

Adult patients with haemodynamically stable

was similar in both groups at a mean of 6.4

condition undergoing elective cardiac surgery

days in the rate control group and 7 days in the

were randomized to receive rate control (medi-

rhythm control group (p=0.76). [N Eng J Med

cines to bring resting heart rate <100 beats per

2016;doi:10.1056/NEJMoa1602002]

minute) or rhythm control (3 g oral amiodarone

Secondary outcomes namely, length of stay

for index hospitalization (5.5 days rate control

administered during hospitalization with or without heart rate-slowing agent).

versus 5.8 days rhythm control; p=0.88), rate

Switches between the two groups were al-

of death (p=0.64), and overall serious adverse

lowed for clinical reasons. Gillinov and team

events (24.8 for rate control vs 26.4 for rhythm

reported a 25 percent group deviation from the

control, per 100 patient months respectively;

assigned therapy due to drug ineffectiveness,

p=0.61) did not differ significantly.

side effects, or adverse drug reactions.

The researchers also reported a stable heart

Patients with history of AF were excluded

rhythm without AF in 93.8 percent of the rate

to avoid changes to their existing treatment

control group and 97.8 percent of the rhythm

protocols.

MAY 2016 CO N F E R E N C E COV E R AG E 37

European Association for the Study of the Liver (EASL) International Liver
Congress 2016, April 13-17, Barcelona, Spain

Long wait over: HCV-infected patients

can receive HCV-positive liver
ELVIRA MANZANO

atients infected with hepatitis C virus (HCV)

who are in need of a transplant can safely

receive a liver from an HCV-positive donor with

a healthy liver biopsy, according to an analysis
of outcomes spanning over 18 years.
The finding should offer comfort to doctors and their patients, given that HCV can now
be cured in almost all patients after a transplant with the introduction of direct-acting an-

The researchers analysed data from 33,668

tiviral therapy, said lead researcher Dr. Zobair

hepatitis C-positive patients who underwent

Younossi from Inova Fairpax Hospital in Falls

transplantation from 1995 through 2013 and

Church, Virginia, US.

were listed in the US Scientific Registry of Trans-

HCV-positive allografts could now be a rea-

plant Recipients. Of these, 1,930 or 5.7 percent

sonably safe option for patients with chronic HCV

received hepatitis C-positive donor liver. [EASL-

infection who are in need of a liver transplant.

ILC 2016, abstract PS040]

In the study, HCV-infected patients who were

The more recent the transplantation the low-

transplanted with an HCV-positive liver did just

er the rates of mortality (adjusted hazard ratio

as well as those who received an HCV-negative

[HR], 0.978;p<0.0001) and graft loss (adjusted

liver. Death and graft loss were comparable be-

HR, 0.960; p<0.0001).

tween patients who received an HCV-positive

Overall survival dropped from just below

liver and those who received an HCV-negative

100 percent in the first year to over 50 percent

liver (p>0.05 for all), Younossi said.

after 10 years, Younossi said.

However, he clarified that an HCV-positive

Many doctors in the US have been using

liver cannot be safely transplanted into a hepa-

theoretically suboptimal donors as patients

titis C-negative recipient because of the risk of

could not wait any longer, he added.

causing runaway hepatitis in an immunosuppressed hepatitis C-negative patient.

The rates at which HCV-infected liver were

being used tripled from 3 percent in 1995 to 9

MAY 2016 CO N F E R E N C E COV E R AG E 38

percent in 2013.
However, Dr. Tom Hemming Karlsen of the

available... this is only for patients who already

have HCV.

Oslo University Hospital in Oslo, Norway, who

More studies are therefore warranted to es-

was not part of the study, commented: We

tablish evidence-based selection criteria for

should not jump to the conclusion that there

HCV-positive donors that will provide patients

is now a donor pool that should be generally

with the best possible risk-to-benefit ratio.

C-EDGE: elbasvir/grazoprevir more

effective, safer for hepatitis C treatment
PEARL TOH

irect-acting antiviral (DAA) treatment combining elbasvir (EBV), an NS5A phosphoprotein

inhibitor, and grazoprevir (GZV), an NS3/4A protease inhibitor, was more effective and better tolerated than the previously recommended regimen
of sofosbuvir plus pegylated interferon with ribavirin (SOF+PR) in patients infected with hepatitis
C virus (HCV), according to the C-EDGE head-tohead* study presented at the EASLs International

C-EDGE results are promising

Liver CongressTM(ILC) 2016 in Barcelona, Spain.

The EBV/GZV combo was effective against

The C-EDGE study was a phase III, random-

HCV genotypes 1 and 4, with 99.2 percent of

ized, parallel-group trial enrolling 255 patients

patients treated with EBV/GZV achieving SVR12

with HCV genotypes 1, 4, or 6 (mean age 48

compared to 90.5 percent of patients in the

years, 99 percent white) who were previously

SOF+PR group. EBV/GZV combination ther-

untreated or nonresponsive to the SOF+PR

apy was especially effective in difficult-to-treat

regimen. [EASL-ILC 2016, abstract PS002]

patients, such as those with liver cirrhosis and

Patients were randomly assigned to oral EBV/

HIV comorbidities.

GZV (50 mg/100 mg, once daily) or SOF+PR (400

Furthermore, EBV/GZV resulted in significant-

mg/weight based, once daily) for 12 weeks and

ly fewer adverse events (AEs) than SOF+PR.

tested for sustained virologic response (SVR12) in

The most common AEs with EBV/GZV were

their blood.

headache (13 percent), fatigue (7 percent), and

MAY 2016 CO N F E R E N C E COV E R AG E 39

nausea (6 percent) versus fever (54 percent),

Currently, there are at least four different

headache (40 percent), fatigue (25 percent),

pharmaceutical companies producing effec-

and asthenia (24 percent) with SOF+PR.

tive HCV drugs and we as hepatologists have

Additionally, EBV/GZV treatment did not re-

to study them well to recommend them to our

sult in any grade 3 or 4 abnormalities in ala-

patients, said Dr. Desmond Wai, a consultant

nine aminotransferase (ALT) or aspartate ami-

hepatologist at the Desmond Wai Liver and

notransferase (AST) levels or red blood cell

Gastrointestinal Diseases Centre in Mount Eliz-

counts. The SOF+PR group had one patient

abeth Novena Specialist Centre, Singapore.

with a grade 3 ALT/AST abnormality and five

However, the medical welfare situation in

patients with grade 3 or 4 haemoglobin decrease.

Asia is different from those in developed West-

The combination of EBV/GZV has shown to

ern countries, where medications are paid for

be more effective than previously recommended

by the government or insurance companies,

treatment options, giving physicians another treat-

said Wai. In Asia, almost all my patients with

ment option against this damaging infection, said

HCV are self-paying patients and frankly, every

lead author Dr. Jan Sperl, a hepatologist at the

cent counts.

Institute for Clinical and Experimental Medicine in

Prague, Czech Republic.

Besides,

combo

treatment

[pegylated

interferon+ribavirin] is still effective in genotypes 2 and 3 patients where cure rate is more

Cost concerns in Asia

than 80 percent.

SOF+PR was previously recommended for

treating HCV according to guidelines from the

*C-EDGE head-to-head: Efficacy and Safety of Combination

American Association for the Study of Liver Dis-

Grazoprevir (MK-5172)/Elbasvir (MK-8742) versus Sofosbuvir+Pe-

eases (AASLD) and EASL but no longer recom-

gylated Interferon+Ribavirin in Hepatitis C Virus Genotype 1, 4 or

mended currently.

6 Infection

MAY 2016 CO N F E R E N C E COV E R AG E 40

European Association for the Study of the Liver (EASL) International Liver
Congress 2016, April 13-17, Barcelona, Spain

Chronic hep B patients treated with

NUCs at higher risk of colorectal,
cervical cancer
ROSHINI CLAIRE ANTHONY

ndividuals with chronic hepatitis B who are

treated with nucleos(t)-ide analogues (NUCs)

have a higher risk of developing colorectal and

cervical cancer, according to a study presented
at the EASLs International Liver Congress
(ILC) 2016 in Barcelona, Spain.
Chronic hepatitis B patients who had been
treated with NUCs had a higher risk of devel-

ceived NUCs. There were 274 cancer cases (5.7

oping colorectal (adjusted hazard ratio [aHR],

percent; inclusive of hepatocellular carcinoma

2.17, 95 percent CI, 1.08-4.36; p=0.029) and

[HCC]) in the NUC-treated group and 538 can-

cervical cancer (aHR, 4.41, 95 percent CI, 1.01-

cer cases (2.1 percent) in the untreated group at

19.34; p=0.049) compared to those who did

a median follow-up of 4.4 years. The mean age

not receive NUCs. [EASL-ILC 2016, abstract

of NUC-treated patients was 46 and for the un-

PS052]

treated group, 35 years.

The risks of developing lung or pleural

Aside from HCC, the most commonly occur-

cancers (aHR, 0.82, 95 percent CI, 0.52-1.31;

ring cancers were lung and pleural cancers (117

p=0.409) and urinary or renal malignancies

in the untreated group vs 28 in the NUC-treated

(aHR, 1.04, 95 percent CI, 0.38-2.81; p=0.944)

group), colorectal cancer (41 vs 15), breast can-

were similar between patients who had NUC

cer (43 vs 4), cervical cancer (33 vs 2), and uri-

treatment and those who did not, as were the

nary/renal malignancies (31 vs 6).

risks of developing all malignancies (aHR, 1.01,

95 percent CI, 0.82-1.25; p=0.899).

In light of these findings, we strongly urge

regular screening of these cancers in patients

Participants were 45,299 chronic hepatitis

taking nucleos(t)ide analogue treatment, said

B patients who were diagnosed between 2000

lead author of the study Dr. Grace Wong, a pro-

and 2012. Of these, 7,323 (16.2 percent) re-

fessor of Gastroenterology and Hepatology from

MAY 2016 CO N F E R E N C E COV E R AG E 41

the Faculty of Medicine, Chinese University of

ral treatment still outweighs the risks, she

Hong Kong, Hong Kong, who presented the

said.

results.
However, Wong cautioned that these results
should not necessarily influence prescribing
decisions.

Wong also recommended that patients

treated with NUCs undergo regular surveillance based on international guidelines.
Colorectal and cervical cancer screening

First of all, the overall risk for all cancers

should be offered to those with risk factors,

is not increased. Second, the risk of colorec-

she said, and advocated for larger cohort

tal and cervical cancer would need indepen-

studies and some mechanistic studies on

dent validation. Even if there is any confirmed

the potential carcinogenic mechanisms to

increased risk, the beneficial effect of antivi-

further establish this association.

MAY 2016 M E E T I N G H I G H T L I G H T S 42

Nutrition therapy for adult ICU

patients: International guidelines
and Asia-Pacific practices
Early delivery of enteral nutrition (EN) can reduce disease severity, decrease complications
and shorten hospital stay for ICU patients. At the Inaugural Meeting of the Asia Pacific
Middle East Working Group on Nutrition Therapy in the ICU, held in April in Cebu,
Philippines, experts reviewed current evidence and practices to develop consensus
statements on nutrition therapy for adult ICU patients in the region. Professor Robert
Martindale of the Oregon Health & Science University, Portland, OR, US, presented the
latest guidelines on adult ICU nutrition therapy from the American Society of Critical Care
Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). Dr.
Marianna Sioson of The Medical City Hospital, Pasig City, Manila, Philippines, presented
results of a recent survey on clinical nutrition practices in ICUs across the region.
ease severity, noted Martindale.
The 2016 SCCM/ASPEN guidelines there-

Prof. Robert Martindale

fore recommend nutritional risk assessment

on admission to the ICU, using tools such
as the Nutritional Risk Screening 2002 [NRS
2002] and the NUTRIC score, followed by
assessment-based

Dr. Marianna Sioson

nutrition

intervention,

said Martindale, a co-author of the guidelines.

[JPEN J Parenter Enteral Nutr 2016;40:159211]
Cross-sectional CT at L3 and cross-sec-

2016 SCCM/ASPEN guidelines

tional ultrasound of the mid thighs are emerg-

ICU patients are a vastly heterogeneous

ing as new assessment tools since body com-

population. Malnutrition in these patients has

position is correlated with nutritional status,

been difficult to define. In contrast, nutritional

said Martindale. Because of the cost and ra-

risk, a new concept in medical nutrition, can be

diation exposure associated with CT scans, we

easily defined and more readily determined by

are now using ultrasound at the bedside per-

evaluation of baseline nutritional status and dis-

formed by trained dietitians.

MAY 2016 M E E T I N G H I G H T L I G H T S 43

The benefit of assessment-based nutrition

Figure 1. Early vs delayed EN: Mortality

intervention is supported by evidence from

Study or subgroup

randomized controlled trials [RCTs], he con-

Moore 1986

tinued. Patients at high nutritional risk, defined

Weight

Risk ratio
M-H, random
Not estimable

Sagar 1979

0.48

2.3%

Not estimable

Chiarelli 1990

Not estimable

Schroder 1991
Eyer 1993

3.7%

1.00

as an NRS 2002 score or a NUTRIC score of

Beier-Holgersen 1996

4.9%

0.50

Carr 1996

1.3%

0.33

5, are more likely to benefit from nutrition in-

Chuntrasakul 1996

2.7%

tervention than patients at low nutritional risk.

Singh 1998

8.2%

1.05

Kompan 1999

1.3%

0.33

Minard 2000

3.0%

0.31

Pupelis 2000

3.2%

0.33

Pupelis 2001

3.1%

Timing and goals of nutrition therapy

Early initiation of EN within 24-48 hours of
ICU admission is recommended for patients
who are unable to maintain volitional intake.
Early provision of EN is associated with a 30
percent reduction in mortality (p=0.05) and a

0.27
Not estimable

Watters 1997

0.14
Not estimable

Dvorak 2004
1.3%

0.31

Peck 2004

11.0%

0.74

Malhotra 2004

26.5%

0.75

Nguyen 2008

17.5%

1.00

Moses 2009

5.6%

1.03

Chourdakis 2012

4.4%

1.10

100.0%

0.70

Kompan 2004

Total

Risk ratio
M-H, random, 95% CI

Heterogeneity: Tau2=0.00; Chi2=7.23; df=15 (p=0.95); I2=0%

Test for overall effect: Z=1.97 (p=0.05)

0.1

EN = enteral nutrition; HR = hazard ratio; CI = condence interval

Adapted from JPEN J Parenter Enteral Nutr 2016;40:159-211.

0.2
0.5
Favours early EN

2
5
10
Favours delayed/none

26 percent reduction in infectious complications (p=0.01) compared with delayed or no

EN. (Figure 1)

Formula selection

A standard high-protein polymeric formula

For most ICU patients, we suggest initiating

is suggested for EN initiation in the ICU. Im-

EN in the stomach. In patients with intolerance

mune-modulating EN formulas should be re-

to gastric EN or a high risk of aspiration, we rec-

served for patients with traumatic brain injury

ommend diverting EN to the small bowel, said

and perioperative patients in the surgical ICU.

Martindale.

In postoperative patients requiring EN, routine

For patients at high nutritional risk, EN

use of an immune-modulating formula containing

should be advanced toward goal as quickly as

both arginine and fish oils is suggested, as this

tolerated over 24-48 hours to provide >80 per-

can reduce infections by 41 percent and length

cent of goal energy and protein within 48-72

of hospital stay by 2.38 days. [J Am Coll Surg

hours. There is now a much greater empha-

2011;212:385-399, 399.e1]

sis on protein. Higher doses of protein in the

In patients with moderate-to-severe acute

range of 1.2-2 g/kg/day should be provided,

pancreatitis who have intolerance to EN, chang-

said Martindale.

ing to a formula containing small peptides and

Gastric residual volumes [GRVs] should

not be used routinely to monitor ICU patients

medium-chain triglycerides is one of the measures suggested to improve EN tolerance.

receiving EN because improvements in EN de-

In patients with sepsis, new data suggest

livery were seen with the elimination of GRV

that arginine is safe and may improve out-

measurements without jeopardizing patient

comes, pointed out Martindale. [Clinical Sci-

safety, he added.

ence 2015;128:57-67] In patients with acute

MAY 2016 M E E T I N G H I G H T L I G H T S 44

lung injury or acute respiratory distress syndrome, no recommendation can be made on

the routine use of an EN formula with an antiinflammatory lipid profile, because the results of
studies are far too inconsistent.
Adjuvant therapies

Figure 2. Use of immune-modulating nutrients in ICUs in Asia Pacic and Middle East
Glutamine

84

Arginine

59

EPA

57

DHA

41

GLA
Others

31
9

Percent of respondents
DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; GLA = gamma-linolenic acid
Adapted from Sioson M, 2016.

The majority of ICUs performed nutrition

The 2016 SCCM/ASPEN guidelines suggest

screening and assessment using standard

that enteral glutamine should not be routinely

validated tools. However, very few used indi-

added to an EN regimen in ICU patients, said

rect calorimetry to calculate patients energy

Martindale.

needs.

A combination of antioxidants and trace min-

About 80 percent of respondents initiated

erals should be provided to all patients requir-

EN within 24-48 hours of ICU admission, and

ing specialized nutrition therapy, he continued.

79 percent progressed EN within 1-5 days,

Probiotics should be used only in select ICU

said Sioson. The most common reason for

patient populations where RCTs have demon-

delayed and inadequate EN was haemody-

strated benefit. Their routine use is not recom-

namic instability and gastrointestinal toler-

mended.

ance, respectively.
Almost all respondents used the gastric

Clinical nutrition practices in the region

route as first-line EN feeding route, but only

A survey in January and February 2016 with

57 percent routinely delivered EN continu-

176 healthcare professionals revealed gaps in

ously. About a third had limited access to EN

clinical nutrition practices in ICUs across Asia

equipment.

Pacific and Middle East.

The survey, conducted by the Philippine Society for Parenteral and Enteral Nutrition (Phil-

Although the majority had access to and

used commercial EN formulas, 38 percent still
used kitchen feeds, said Sioson.

SPEN) with support from the Nestle Nutrition In-

About half of the respondents used im-

stitute, showed that the expertise in the region

mune-modulating nutrients, mostly in patients

is not being fully utilized. For example, while

with trauma (65 percent) or cancer (55 per-

most ICUs in the region had access to dietitians

cent) or in perioperative patients (49 percent).

and pharmacists, daily access was available to

A majority still used glutamine, while more

only 43 and 59 percent, respectively, reported

than half used arginine and eicosapentaenoic

Sioson, immediate past president of PhilSPEN.

acid. (Figure 2)

Only 36 percent had dedicated nutrition sup-

Most respondents used probiotics, laxa-

port teams [NSTs], and the NSTs were utilized

tives and motility agents only when indicated.

only about half of the time.

However, 70 percent had no ICU dysphagia

MAY 2016 M E E T I N G H I G H T L I G H T S 45

protocol, and only half screened for dysphagia

teaching and lectures could improve nutrition

before transitioning to oral feeding.

delivery.

Surprisingly, 8 percent of respondents did

not routinely keep the head of the bed elevat-

Conclusion

ed to prevent aspiration, pointed out Sioson.

Early EN provides both nutritional and

Eighty-four percent still used GRVs in pa-

non-nutritional benefits to ICU patients. While

tient monitoring, and 21 percent had arbitrary

the 2016 SCCM/ASPEN guidelines provide a

GRV cut-offs depending on the attending

useful guide, they should not take priority over

physician.

clinical judgement, concluded Martindale.

Barriers to implementing nutrition prac-

The PhilSPEN survey created an impetus

tices in ICUs included lack of education and

for the development of consensus statements

training, manpower limitations, inadequate

on adult ICU nutrition practices for Asia Pacific

access to certain formulas and nutrients,

and Middle East. The statements, currently

and patients financial difficulties, she not-

in development, will address gaps in clinical

ed. Most respondents agreed that nutrition

practice and offer specific solutions to improve

therapy is important in ICUs, and that bedside

patient care.

Diagnostic Musculoskeletal Ultrasound &

Injection Technique Workshop
19 21 August 2016 | Hong Kong

Hands-on Course
Focusing on Musculoskeletal Sonoanatomy of the Extremities,
Hip & Spine using Live Models and Porcine Cadavers

Nerve and Spine Track Available

Programme
The programme includes scanning on Live Models and practicing ultrasound
guided injection on Porcine Cadavers. 90% of all sessions are hands-on.

1:4 Faculty to Attendees Ratio

Course Faculty
Thomas B Clark
DC, RVT, RMSK
MSKUS, Course Chair

Stanley KH Lam
MBBS(HK), MScSEM(Bath)
Hong Kong Institute of Musculoskeletal Medicine

Keith Hansen
DC, RMSK
Advanced Rheumatology

Allen HY Ngai
MBBS(HK), MScSM&HS(CUHK)
Hong Kong Institute of Musculoskeletal Medicine

Andrew KK Ip
MBBS(HK), MScSEM(Bath)
Hong Kong Institute of Musculoskeletal Medicine

Rajesh Singh
MBBS-Honours(UNSW), MOrthSurg-Distinction(UM)
Monash University Malaysia

Manoj K Karmakar
MD
The Chinese University of Hong Kong

Regina WS Sit
MBBS(HK), FHKAM(FamilyMedicine)
Hong Kong Institute of Musculoskeletal Medicine

Mark WW Lai
MBBS(HK), MScSM&HS(CUHK)
Hong Kong Institute of Musculoskeletal Medicine

Shawn P Tierney
DC, RMSK
Atlantic Chiropractic

Who Should Attend?

Ricky WK Wu
MBBS(HK), PGDipMSM(Otago)
Hong Kong Institute of Musculoskeletal Medicine

Family Physicians
Musculoskeletal Physicians
Rehabilitation and Pain Physicians
Sports Physicians

Venue
Function Rooms, 3/F., South Tower, The Salisbury YMCA of Hong Kong
41 Salisbury Road, Tsimshatsui, Kowloon, Hong Kong

Registration
The Registration fee is HK$24,900 / US$3,250
Please register at www.hkimm.hk

Further Information
Please visit www.hkimm.hk or contact the meeting secretariat at
(852) 2155 8557 / 3153 4374 or e-mail to meeting.hk@mims.com

MAY 2016 H U M O U R 46

Welcome aboard my son. Here youll

find eternal peace and happiness.
No more wine, women and song!

If the age spots are whats causing your anxiety,

I recommend that you see a dermatologist.

Charlie, talk to me. The Cialis kicked in yet?

Did I remember to put him back in the fridge?

This part always creeps

me out!

I dont have my glasses.

Does it say malignant?

Were marooned on this island

and all you worry about is the
Viagra pills you left on the ship!

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