SEPTEMBER 2014

Scientists discover first biomarkers

predictive of severe OA

FORUM
Urgent global
action needed
to combat
antimicrobial
resistance

NEWS

CONFERENCE

RESEARCH
REVIEWS

Higher DAS scores

in obese RA
patients may lead
to more aggressive
therapy, better
outcomes

Short TB
regimen shown
to be effective

Atrophic gastritis
may raise
osteoporosis risk
in postmenopausal
women

S E P TE M B E R 2 01 4

Scientists discover first biomarkers

predictive of severe OA
GREG TOWN

ered the most effective approach for the management of OA. However, there has been no

he presence of microRNA (miRNA) bio-

way to identify OA early, when the disease is

markers in the blood is correlated to the

still clinically silent.

development of severe osteoarthritis (OA) of

We need to identify those individuals who

the knee or hip, according to new research

are at risk of developing this disease. This is

presented at the European League Against

crucially important, said Beyer. At the mo-

Rheumatism Annual Congress, held recently in

ment, there are no markers or indicators that

Paris, France.

will show us who is at risk of that and we need

The findings indicate that for the first time

we will be able to predict the risk of severe

to develop biomarkers that can predict the development of this disease.

osteoarthritis, before the disease starts to sig-

However, this new study suggests that three

nificantly impact a persons life, allowing us to

miRNAs could be used as biomarkers to pre-

take preventative action early on, said lead au-

dict severe OA, said Beyer, adding that: let-7e

thor Dr. Christian Beyer from University Erlan-

was our most promising single microRNA and

gen-Nuremberg, Germany. Through the early

we also found a nice correlation between let-

identification of osteoarthritis we can decrease

7e levels and the number of joint replacement

both the impact of the disease on individuals

surgeries due to severe OA. We found that the

and the major socioeconomic burden severe

lower those let-7e levels were, the higher was

disease poses.

the risk for receiving more than one joint re-

The researchers analyzed blood samples

from patients with OA over a follow-up period

placement because of severe osteoarthritis of

the knee or the hip.

of 15 years, testing for the presence of miRNAs

OA is a common musculoskeletal disorder

and occurrence of OA. Out of the 816 patients

affecting 10 percent of people worldwide. It is

followed, 67 had 1 total joint replacement for

one of the top 10 most disabling diseases in

severe knee or hip OA. The results of serum

developed countries and a major cause of knee

analyses demonstrated that severe OA was

and hip replacements. Osteoarthritis is the

correlated with three miRNA biomarkers known

most common form of arthritis and it is a major

as let-7e, miR-454 and miR-885-5p. [Abstract

socioeconomic burden, said Beyer. Our study

OP0003]

now opens many new questions that need to be

Prevention and early treatment is consid-

addressed by future studies.

S E P TE M B E R 2 01 4

New technique enables targeted,

controlled delivery of pain meds
ELVIRA MANZANO

S researchers have developed a biodegradable nanoscale film that can be used

to deliver targeted pain medications, either directly through injections or by coating implantable medical devices, in a controlled manner.
The film can be implanted into the patient to
release active drug for more than 14 months,
said study author Professor Paula Hammond

The biodegradable film provided steady drug doses to

targeted sites for 14 months.

from the Koch Institute for Integrative Cancer

Research at Massachusetts Institute of Technol-

after release, suggesting that the method does

ogy in Cambridge, Massachusetts, US. The

not reduce the potency of the drug.

technique can reduce toxicity to vital organs

Normally you need a reservoir or a device

typically caused by systemic administration and

to get long-term drug release and you have this

decrease the need for medical intervention be-

foreign object retained in the body. But with this

cause of its long-lasting release.

biodegradable film, you dont have to go in or

To make the film sturdy enough to limit hy-

recover it, said Mr. Bryan Hsu who helped de-

drolysis a reaction by which the bodys water

velop the project as a doctoral student in Ham-

breaks down the bonds in a drug molecule the

monds lab.

researchers utilized a layer-by-layer technique

The treatment technique has future appli-

of attaching drug molecules to layers of thin-film

cations for a broad spectrum of chronic or re-

coating. The layering strategy also allows them

calcitrant diseases, for example tuberculosis

to adjust the dose of medication being delivered

which requires oral antibiotics daily for at least

to targeted sites.

6 months to destroy the Mycobacterium tuber-

The effect was demonstrated with diclofenac,

culosis bacteria.

a nonsteroidal anti-inflammatory drug used to

Moving forward, the team is looking at opti-

treat pain and inflammation associated with

mizing the technique for different bodily environ-

arthritis. The layering technique allowed diclof-

ments, tests and medications for chronic pain.

enac to produce substantial painkilling effect

The idea is to develop something that could cre-

through COX (cyclooxygenase) inhibition at a

ate an easier lifestyle for people with chronic pain

constant rate. Diclofenac also remained active

and inflammation, the researchers said.

S E P TE M B E R 2 01 4

FORUM

Urgent global action needed

to combat antimicrobial resistance
Remarks by Dr. Margaret Chan, WHO director-general, at the recent Ministerial Conference
on Antimicrobial Resistance in The Hague, Netherlands.

he world has much to learn from the Netherlands.

In human medicine, the Scandinavian coun-

tries and the Netherlands have the strictest policies governing the prescribing of antimicrobials.
And they have the lowest rates of drug resistance.
WHO has been warning the world about the
threat from antimicrobial resistance for more
than two decades. Already in 1994, scientists
convened by WHO described the rise of antimicrobial resistance as an alarming crisis calling
for urgent measures.
A typical pattern has emerged. A report is

Our most recent report, issued in April, was

issued. The media respond with sensational

the most alarming yet. Drugs that were once

coverage. Politicians give speeches and offer

lifesavers are now worthless. Hospitals have be-

quotes that further underscore the high level

come hotbeds for the transmission of highly re-

of alarm. But then nothing much happens

sistant superbugs, increasing the risk that hos-

worldwide. Dangerous practices continue. The

pitals kill rather than heal. For a growing number

consequences spread. And the problem gets

of serious infections, doctors are empty-hand-

worse.

ed. The rise of resistance has vastly outpaced

These reports have documented trends,

the development of replacement drugs.

explained contributing factors, and issued de-

Antimicrobial resistance is not a future threat

tailed policy advice targeted at multiple audi-

looming on the horizon. It is here, right now, and

ences, from consumers, prescribers, and medi-

the consequences are devastating.

cal schools, to regulatory authorities, veterinary

Here is the central question. How bad will

services, and pharmaceutical companies. This

things have to get before the recommendations

has not been enough to provoke real worldwide

we have been making for decades are finally act-

change.

ed upon? How much more evidence do we need?

In the midst of deeply alarming trends, I see

some positive signs.

S E P TE M B E R 2 01 4

FORUM

of animals, and an increased potential for the

misuse of antimicrobials.

The May World Health Assembly adopted a

Some analysts have compared the threat of

resolution asking WHO to develop a draft global

antimicrobial resistance with the threat from cli-

action plan to combat antimicrobial resistance.

mate change. Both are already here. Both are

The resolution specifically asked WHO to col-

caused by human activities. And both are global

laborate with FAO and OIE in a multisectoral ap-

threats that demand global solutions, including

proach that brings together human health, ani-

solutions to problems that are caused by en-

mal health, and agriculture.

trenched industry practices.

As in human medicine, veterinary services
depend on safe and effective antibiotics to treat

D
 rugs that were once lifesavers
are now worthless 

sick animals. The focus of concern is the routine

use of antibiotics in food-producing animals in
very large quantities, especially for growth promotion and for prophylaxis when animals are

This meeting is being held to give WHO ex-

crowded together under unsanitary conditions.

pert guidance as we develop this dimension of

This concern was formally recognized in 2003

the draft action plan. Tripartite collaboration be-

by a scientific assessment jointly convened by

tween FAO, OIE, and WHO is well-established,

FAO, OIE, and WHO. The assessment found

productive, and innovative, offering a solid foun-

clear evidence of adverse consequences for

dation for joint work on the action plan.

human health, including the transmission of re-

Two ominous trends provide additional in-

sistant bacteria to humans through food.

centives to take urgent and sweeping action.

The consequences were judged particularly

First, as incomes rise in the developing world,

severe when pathogens in animals developed

the use of antibiotics soars, fueled by unregu-

resistance to medicines that are critically impor-

lated sales and ready access on open markets.

tant for human health.

Second, as incomes rise, the demand for meat

likewise soars.

One outcome was the first WHO list of critically important antimicrobials for use in human

According to FAO data, per capita consump-

medicine, issued in 2005. These lists are regu-

tion of meat in developing countries has more

larly revised to guide the development of risk

than tripled since 1960. Over the same period,

management strategies for the use of antibiotics

meat production in East and South-East Asia in-

in food-producing animals.

creased more than 100-fold.

The list is now complemented by an OIE list

In other words, economic progress, the very

of antimicrobial agents of veterinary importance,

goal of so many development initiatives, means

which recommends the restricted use of certain

increased demand for meat, increased farming

agents.

The challenge now is to move from recommended measures and instruments like these
lists to implementation, to real and urgent action
at global as well as national level.

S E P TE MB E R 2 01 4

above all, the almost total absence of regulatory

capacity in many countries.
Financial and other incentives undermine the
responsible and prudent use of antimicrobials.
These agents can be purchased over the Internet, adding to the challenges. In many develop-

A
 s incomes rise in the developing
world, the use of antibiotics soars,
fueled by unregulated sales and
ready access on open markets 

ing countries, doctors look to pharmaceutical

companies as their principal source of prescribing information.
The intensely competitive meat industry
is driven to produce ever higher quantities at
ever lower prices. Hospitals, even in the richest
countries, fail to follow good practices for infec-

To stop or reverse some extremely dangerous trends, difficult policy issues need to be
addressed.

tion control, including things as basic as hand

hygiene.
These are some of the issues that need to

Our three agencies face similar challenges,

be addressed as we jointly develop the global

including poor surveillance in the health and

action plan to combat antimicrobial resis-

animal sectors, weak laboratory support and,

tance.

S E P TE MB E R 2 01 4

N E WS

Q and A: Discovering nitric oxide,

a powerful vasodilator
Nitric oxide (NO) is a pervasive signaling molecule that has multiple functions in the body.
Critically, NO is a powerful vasodilator with a very short half-life. Research on NO and its
functions in the cardiovascular system earned Dr. Louis Ignarro, a pharmacologist at the
University of California School of Medicine in Los Angeles, California, US, and two other
colleagues the 1998 Nobel Prize in Medicine. In an interview with Medical Tribunes Radha
Chitale, Ignarro discussed the journey from dynamite by-product nitroglycerine to the
discovery that endothelial cells are capable of producing their own NO, and the implications
for cardiovascular health.
As a pharmacologist, how did you begin
looking more closely into nitric oxide (NO)
as it related to cardiovascular disease
(CVD)?
NO was known to be one of the pollutant
gases in the atmosphere, where it reacts with
oxygen to form nitrogen dioxide. Being a pharmacologist, its important that I understand the
mechanisms of action of drugs how they work.
The drug in question was nitroglycerin, which
was the active explosive in dynamite but has
been known to be a vasodilator, to relieve and
lower blood pressure, and to relieve angina
since the Alfred Nobel dynamite factories in the
1870s. Nitroglycerin is available as a tablet to be
placed under the tongue.
In the lab, we were discussing how nitro-

Exercise stimulates nitric oxide production, which is

protective against CVD.

with platelet aggregation to inhibit blood clotting.

glycerin works. To make a long story short,

nitroglycerin was metabolized to NO in the ar-

How did your work compare to what your

terial tissue. We found it was a very potent va-

peers were studying at the time?

sodilator and that NO was the active species in

The key work we did between 1978 and

nitroglycerin. We also found it could interfere

1980. By 1980, there were fewer than 100 publi-

S E P TE MB E R 2 01 4

N E WS

cations on NO from about three or four labs, one

Every pharmaceutical company was doing

important piece of research in particular being

research on NO trying to develop drugs that

the discovery that NO could elevate and stimu-

could metabolize to NO, but you cant put a gas

late [the nucleotide messenger molecule] cyclic

in a pill. We do not have a drug that works exclu-

guanosine monophosphate (cGMP) formation,

sively by stimulating NO. We can capitalize on

which was in about 1977. With increased levels

the vasodilation capacities of existing therapies,

of cGMP, the response is relaxation of vascular

particularly beta blockers that selectively target

smooth muscles vasodilation.

beta 1 receptors.

In 1987, we showed that mammalian tissue

Ultimately, hypertension is the starting point

can make its own NO and the following year

for all the heart diseases we know because the

there were over 1,000 publications and even

endothelial damage leads to subsequent stroke,

more in the following years. It just exploded.

heart attack and heart failure, so its a good idea

to control blood pressure early.

Is there some property that makes NO particularly unique as a signaling molecule?

NO is a volatile gas, and before its role in vasodilation was discovered, no one was thinking

What are the most significant threats to

heart health, particularly factors that are
contributing to the incidence of CVD?

that a gas could be a signaling molecule, par-

In the last 15 years, we have lots of evidence

ticularly how it might be made, stored, released

to show that a healthy diet and routine exercise

and what receptors it would interact with.

that increases heart rate stimulates NO forma-

But its nature makes it a beautiful signaling

molecule because you dont want the initial sig-

tion in all the arteries. Over time, this consistent

NO production can be protective against CVD.

nal to last too long. You just want it to be there

While globally about 50 percent of people

and disappear. Because NO is so unstable,

likely suffer from some kind of CVD, less than

it has to elicit an effect immediately once it is

2 percent of people in small subpopulations of

produced.

active individuals such as professional athletes

and consistent exercisers suffer in the same

Discuss some of the most important treat-

way. Now people say the majority of CVD is pre-

ments that have resulted from your research

ventable or reversible.

on NO.

General practitioners or others with practical

As experiments went on, we saw how our

concerns should know that we only have one

own body makes NO to keep blood pressure

layer of endothelial cells that is one cell-layer

down and normal, prevent unwanted blood clot-

deep lining our blood vessels, and these are the

ting and prevent the development of atheroscle-

only cells that produce NO. However, its never

rosis. Ultimately, it prevents heart failure.

too late to reverse endothelial damage.

S E P TE MB E R 2 01 4

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10

Short TB regimen shown to be

effective
DR. CAROL TAN

novel tuberculosis (TB) treatment regimen

that is cheaper and given over a shorter

time period compared to the standard treatment regimen holds tremendous promise, according to Dr. Daniel Everitt, senior medical
officer at the Global Alliance for TB Drug Development.
In the open-label clinical trial conducted in
eight centers in South Africa and Tanzania, the
new TB regimen consisting of moxifloxacin (M),
nitroimidazole Pa-824 (PA), and pyrazinamide
(Z) was evaluated for effectivity and safety, and
was compared to the standard regimen of isoniazid (H), rifampicin (R), Z, and ethambutol

sensitive TB and 26 patients with drug-resistant

(E). The results of the research were presented

TB. The median age of the participants was 28

at the 20th International AIDS Conference in

years old. Thirty-five percent were female, and

Melbourne in July 2014.

19.5 percent were co-infected with human im-

Drug sensitive TB patients were randomized

munodeficiency virus. All patients who received

to receive one of three treatment regimens: M

the experimental regimen had greater average

400 mg, PA 100 mg, and Z 1500 mg (M-PA100-

reductions in CFU counts compared to control,

Z); M 400 mg, PA 200 mg, and Z 1500 mg (M-

but only those who received the M-PA200-Z

PA200-Z); or weight-adjusted HRZE. Patients

regimen had a statistically significant decrease.

with multi-drug resistant TB received the M-

In addition, patients who received the M-

PA200-Z regimen. The primary endpoint was

PA200-Z regimen had significantly shorter

the rate of change in colony forming units (CFU)

median time to the first negative culture at 28

from sputum samples over a period of 8 weeks.

days, compared to the median time of 35 days

for those receiving standard treatment. The

Favorable efficacy and safety profile

The study included 181 patients with drug-

percentages of grade three and four adverse

events were similar in all treatment groups.

S E P TE M B E R 2 01 4

N E WS

11

The authors concluded that the M-PA-Z

duration is advantageous in promoting bet-

regimen has active bactericidal activity against

ter patient compliance, and consequently de-

both drug-sensitive and drug-resistant TB, and

creased drug resistance.

is significantly more effective than HRZE for

drug-sensitive TB.

STAND Trial

Dr. Everitt added that compared to the stan-

Following the favorable results of this initial

dard TB regimen which necessitates 6 months

study, the Global Alliance for TB Drug Develop-

of treatment for drug sensitive TB, the novel

ment is set to launch a bigger trial known as

M-PA-Z regimen is proposed to be given as a

the Shortening Treatment by Advancing Novel

4-month regimen only. The shorter treatment

Drugs (STAND) trial.

S E P TE MB E R 2 01 4

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12

Suspect OSA in patients with

unexplained daytime sleepiness
ELVIRA MANZANO

cally relevant symptom of OSA, but clinicians

should also include in their assessment other

dult patients who are excessively sleepy

symptoms such as fatigue, insomnia and snor-

during the day for no apparent reason

ing, and risk factors such as obesity, said the

should be targeted for assessment of obstruc-

guideline authors.

tive sleep apnea (OSA) using a sleep study, a

Clinicians are not advised to assess OSA

new guideline from the American College of

in the absence of daytime sleepiness or treat

Physicians (ACP) recommends.

patients with low AHI scores as evidence sug-

Sleep study records patients brain activity,

gests neither improves clinical outcomes.

eye movements, heart rate, and blood pressure

Of note, portable monitoring in patients with

during sleep to diagnose OSA and determine

chronic lung disease, congestive heart failure,

disease severity.

neurologic disorders and other major comor-

In patients whom OSA is suspected, the

bidities is also not recommended as very few

guideline recommends full-night, in-laboratory

studies included these patients. There is also

polysomnography (PSG) to establish the diag-

little evidence for pre-operative screening for

nosis. This test requires specialized facilities,

OSA and its effect on surgical outcomes.

is expensive and demands that patients spend

The guideline, which is based on reviews of

the night under observation in a foreign envi-

peer-reviewed studies published from 1996 to

ronment, but yields the most accurate diagnos-

May 2013, is developed to provide clinicians

tic information. [Ann Intern Med 2014;161:210-

with guidance on diagnosing OSA. For guid-

220]

ance on treatment, clinicians could refer to the

Home-based portable sleep monitors may

ACP guideline on the management of OSA.

be used as an alternative in patients without

Obstructive sleep apnea is a serious health

comorbid conditions or when PSG is not avail-

condition that is associated with cardiovascular

able, although these can yield substantially

disease, hypertension, cognitive impairment,

different scores on the apnea-hypopnea index

and type 2 diabetes, said ACP president Dr.

(AHI), which accounts for the number of paus-

David Fleming. It is important to diagnose indi-

es in breathing per hour of sleep.

viduals with unexplained daytime sleepiness so

Daytime sleepiness (hypersomnia) is a clini-

that they can get the proper treatment.

S E P TE M B E R 2 01 4

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13

Paracetamol no better than placebo

for back pain
ELVIRA MANZANO

At 3 months, 85 percent of patients in the

regular paracetamol group and 83 percent in

aracetamol did not work any better than

the as-needed group reported sustained recov-

placebo at improving recovery time in pa-

ery from pain compared with 84 percent in the

tients with acute low back pain regardless of

placebo group. Similar results were reported for

whether the drug was taken regularly or when

sleep quality and physical and mental scores

required only, a study has shown.

(on the Short Form 12 quality of life tool).

The Paracetamol for Low-Back Pain (PACE)

Overall, 19 percent of patients experienced

trial showed there was no difference in the re-

one or more adverse events, with no difference

covery time between patients treated with

in rates across the three groups. Use of rescue

paracetamol in regular doses and those given

medication (naproxen) was minimal and similar

the placebo (17 days versus 16 days). Patients

across the study population.

receiving paracetamol on as-needed doses also

Dr. Chung-Wei Christine Lin of the George

had similar recovery time at 17 days. [Lancet

Institue for Global Health, University of Sydney,

2014; doi:10.1016/S0140-6736(14)60805-9].

and co-author of the study, said patients should

Paracetamol also had no effect on pain, dis-

weigh the benefits of taking medicine for any

ability, function, global symptom change, sleep

small amount of pain relief over the potential

or quality of life, said lead author Dr. Christo-

side effects.

pher Williams from the University of Sydney in

In an accompanying commentary, Dr. Bart

Sydney, Australia. The results suggest the need

W. Koes and Dr. Wendy Enthoven of Erasmus

to reconsider the universal recommendation to

Medical Center in Rotterdam, Netherlands, said

use paracetamol as a first-line treatment for low

guidelines should not be changed on the basis

back pain.

of a single trial. More robust and consistent evi-

The PACE trial included 1,643 patients (mean

dence, including verification of results in other

age, 45 years) from 235 primary care centers in

patient populations, are needed. In the mean-

Australia with acute low back pain, randomized

time, they said doctors and patients should

to regular paracetamol (thrice daily, 3,990 mg/

be aware that paracetamol may not be effec-

day), paracetamol as-needed (up to 4,000 mg/

tive for acute back pain and this is something

day), or placebo for up to 4 weeks, or until re-

that should affect their decision when starting

covery. All participants were followed up for 3

paracetamol. [Lancet 2014; doi:10.1016/S0140-

months.

6736(14)60978-8]

S E P TE M B E R 2 01 4

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14

Tree nuts help lower blood sugar

in diabetics
RADHA CHITALE

Centre of St. Michaels Hospital in Toronto, Canada, said that nuts probably tended to take the

review of tree nut consumption showed that

place of some carbohydrates in the diet, thereby

including about two servings of these nutri-

lowering the dietary glycemic load.

ent-rich foods in a persons diet could decrease

plasma glucose levels and fasting glucose.

The nuts micronutrient profile may also play

a role in decreasing diabetes risk and improv-

While tree nuts such as almonds, walnuts,

ing glycemic control. Magnesium, found in

coconuts and pecans (though not peanuts,

high concentrations in many tree nuts, might

which are legumes) are frequently included in

be important for insulin-mediated glucose up-

heart-healthy diets such as those from the Medi-

take or proper tyrosine-kinase activity in insulin

terranean region or Dietary Approaches to Stop

receptors.

Hypertension (DASH), data linking nut con-

And while tree nuts may be low in sugar,

sumption to a lower incidence or risk of type 2

they are high in fat, but it is monounsaturated

diabetes is spotty.

fat, which in some studies have been shown to

The review included 12 trials of 450 middle-

reduce HbA1c levels in higher quantities.

aged adults with diabetes that included key

High quantities of tree nut consumption over

glycemic endpoints. [PLoS ONE 9(7):e103376.

time may also be important in diabetes control.

doi:10.1371/journal.pone.0103376]

Studies shorter than 12 weeks were less likely

Adults who consumed a median 56 g/day

to include patients who had lower HbA1c levels

of tree nuts showed a 0.07 percent decrease in

compared to those of 12 weeks or more. Stud-

HbA1c levels and 0.15 mmol/L lower fasting glu-

ies with a crossover design had a washout pe-

cose, both of which were significant, according

riod of up to 8 weeks and demonstrated a corre-

to a pooled analysis over a median 8 weeks.

sponding smaller effect of tree nut consumption

Improvements were not as clear for other glycemic endpoints.

on blood sugar compared to trials with a parallel

design.

Although significant advantages for fasting

Limits of the meta-analysis included whether

insulin and homeostasis model assessment of

the follow-up period in many of the trials was long

insulin resistance were not seen, the direction

enough to significantly affect glycemic control,

of effect favored the tree nut intervention, the

as well as between-study heterogeneity in out-

researchers said.

come monitoring. Still, most of the data pointed

Lead researcher Dr. John Sievenpiper of the

Clinical Nutrition and Risk Factor Modification

towards including tree nuts in the diet for diabetes

benefits.

S E P TE M B E R 2 01 4

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15

Lancet launches series on health

care needs of sex workers
CHUAH SU PING

ported that the decriminalization of sex work

would have the greatest effect on the course

he Lancet has launched a special series is-

of HIV epidemics across all settings, averting

sue that highlights the global HIV epidemic

33-46 percent of HIV infections in the next de-

among sex workers, a key but overlooked popu-

cade alone.

lation for HIV prevention. The series launched

The series also highlights the increasing bur-

at the 20th International AIDS conference in

den of HIV being faced by male sex workers.

Melbourne consists of seven papers that aim

Male sex workers with male clients often do not

to investigate the complex health issues faced

identify themselves as gay or bisexual and have

by sex workers worldwide, and calls for the de-

female intimate partners. The heterosexual

criminalization of sex work, in the global effort

identity in male sex workers represents a risk

to tackle the HIV/AIDS epidemic. [Available at

factor for HIV transmission to their non-paying

www.thelancet.com/series/HIV-and-sex-work-

female partners. [Available at www.thelancet.

ers. Accessed on 23 July 2014]

com/series/HIV-and-sex-workers/infographic.

Sex workers worldwide face substantial bar-

Accessed on 23 July 2014]

riers in accessing prevention, treatment and

In a separate paper addressing the vulner-

care services, largely due to stigma, discrimina-

abilities of this population, Baral SD, et al wrote,

tion and criminalization in the societies in which

Evidence-based and human rights-affirming

they live. These social, legal and economic in-

services dedicated specifically to male sex work-

justices, highlighted The Lancet, contribute to

ers are needed to improve health outcomes for

their high risk of acquiring HIV. Often driven un-

these men and the people within their sexual

derground by fear, sex workers remain under-

networks.

served by the global HIV response.

Ultimately, as Professor Chris Beyrer of the

Female sex workers (FSWs), a paper from

Johns Hopkins Bloomberg School of Public

the series highlighted, continue to bear a dis-

Health in Baltimore, Maryland, US, and pres-

proportionately large burden of HIV infection

ident-elect of the International AIDS Society

worldwide. Despite decades of research and

noted in his paper An Action Agenda for HIV

program activity, the epidemiology of HIV and

and Sex Workers, addressing HIV in sex work-

the role that structural determinants have in

ers will require sustained community engage-

mitigating or potentiating HIV epidemics and

ment and empowerment, continued research,

access to care for FSWs is poorly understood,

political will, structural and policy reform, and

wrote Shannon K, et al. The researchers re-

innovative program.

S E P TE MB E R 2 01 4

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16

High work stress linked to increased

T2D risk
CASSIE-ANNE LOW

12.7 years, however, 291 cases of T2D were

identified. Participants with high levels of job

tress at work may significantly increase the

stress at baseline were found to have a 45 per-

risk of developing type 2 diabetes (T2D),

cent higher risk of diabetes than those with low

according to a new study.

The population-based study, funded by the

levels of job stress (hazard ratio [HR]1.45 ,95%

CI, 1.00-2.10; p=0.48).

German Center for Diabetes Research and the

Competence Network Diabetes Mellitus in Germany, sought to determine whether a higher

R
 oughly one in five people in

amount of stress at the workplace had any im-

employment is affected by high

pact on T2D risk.

levels of mental stress at work 

Results showed that individuals under high

levels of stress or pressure at work and who feel
they have little control over their daily activities

According to our data, roughly one in five

had a 45 percent higher chance of developing

people in employment is affected by high levels

T2D compared to people with low stress levels.

of mental stress at work. By that, scientists do

In the study, scientists from the Institute

not mean normal job stress but rather the situ-

of Epidemiology II at the Helmholtz Zentrum

ation in which the individuals concerned rate the

Mnchen in Munich, Germany together with

demands made upon them as very high, and at

Professor Johannes Kruse from the Univer-

the same time they have little scope for maneu-

sity Hospital of Giessen and Marburg in Mar-

ver or for decision making. We covered both

burg, Germany looked at data collected from

these aspects in great detail in our surveys,

over 5,300 employed individuals aged 29 to 66

said Professor Karl-Heinz Ladwig from the In-

years, identified from the previous MONICA/

stitute of Epidemiology II, Helmholtz Zentrum

KORA cohort study. The study focused on the

Mnchen in Munich, Germany. In view of the

development and course of chronic diseases,

huge health implications of stress-related disor-

particularly myocardial infarction and diabetes.

ders, preventive measures to prevent common

None of the participants were found to have

diseases such as diabetes should therefore

T2D at baseline. Over a median follow-up of

also begin at this point.

S E P TE M B E R 2 01 4

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

17

European League Against Rheumatism (EULAR) Annual Congress,

June 11-14, Paris, France

Risk of heart attack higher in Sjgren

patients
ELVIRA MANZANO

and risk modification can be effected to reduce

the risk of future heart attacks.

atients with Sjgren syndrome (SjS), an

The researchers sought to determine the risk

autoimmune rheumatic disorder character-

of first MI or stroke among 1,176 adult patients

ized by inflammation of the salivary and lacrimal

(age >18 years) diagnosed with SjS in British

glands, have a two-fold increased risk of devel-

Columbia between 1990 and 2010 and who re-

oping heart attack compared with controls from

ceived care. Each SjS patient was matched with

the general population independent of tradition-

10 non-SjS controls of the same gender, age

al risk factors, a new study has shown.

and year of follow-up.

The incident rate ratio (IRR) for myocardial

Among SjS patients, 28 developed MI, with

infarction (MI) was 2.36 (95% CI, 1.40-3.31) in

an incident rate (IR) of 7.7 per 1,000 person-

the SjS population. The risk of MI was almost

years, compared with 138 (IR, 3.5 per 1,000 per-

four-fold higher within the first year after diag-

son-years) in the non-SjS cohort. Similar trends

nosis (relative risk [RR], 3.6 95% CI, 1.67.3)

were seen for stroke but because stroke inci-

and persisted for up to 5 years. There was also

dents were fewer, the study was not powered

a non-significant trend towards an increased

to detect statistical significance. Adjusting for

risk of stroke in this cohort of patients. [Abstract

other CV risk factors (angina, chronic obstruc-

OP0212]

tive pulmonary disease, obesity, number of hos-

This suggests that inflammation, which is

pitalizations, and Charlson comorbidity index)

highest around the time of diagnosis, is likely to

and medications, did not make any significant

be the main driver of risk during early disease,

change in results for both heart attack (RR, 2.4)

said principal investigator Assistant Professor

and stroke (RR, 1.6).

Antonio Avia-Zubieta from the University of

British Columbia in Vancouver, Canada.
After 5 years, the risk of MI decreased (RR,
1.9 95% CI, 0.6-5) in the SjS group.

In a press briefing following the presentation,

Professor Gerd Burmester from the Charite University Hospital in Berlin, Germany, and president-elect of EULAR said CV risk among SjS

Avia-Zubieta said both patients and clini-

patients has been grossly neglected and under-

cians should be aware of this risk and time trend

appreciated. We need to better understand the

so cardiovascular (CV) prevention, surveillance,

risks and complications of this disorder.

S E P TE M B E R 2 01 4

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18

European League Against Rheumatism (EULAR) Annual Congress,

June 11-14, Paris, France

Higher DAS scores in obese RA

patients may lead to more aggressive
therapy, better outcomes
GREG TOWN

bese patients with rheumatoid arthritis

(RA) have higher disease activity scores

(DAS) than non-obese patients, regardless of

their disease stage.
This was a key finding of a large international
cohort study involving 3,534 patients from the
METEOR Foundation International RA database.
[Abstract OP0196]

Excessive inflammation could lead to more aggressive

treatment in obese RA patients.

Increasing levels of body fat are associated

with heightened production of proinflammatory

occurs more frequently in women than in men

signaling proteins and raised levels of inflamma-

and is more prevalent in developed nations.

tory markers, said researcher Dr. Christopher

Clinical remission is the optimal aim of RA treat-

Sparks, clinical research fellow, Institute of Age-

ment and a treatment approach involving reduc-

ing and Chronic Disease, University of Liverpool,

tion of DAS scores has been shown to be more

Liverpool, England. This systemic inflammation

effective in achieving this aim than usual care.

could inflate standard DAS scores and mean

In the study, clinical data from the METEOR

that obese patients receive more aggressive

database were used to identify early (disease

treatment than their non-obese counterpart...

duration < 12 months; n=1,553) and estab-

Not only do these results provide an explanation

lished (disease duration 12 months, n=1,981)

for the paradoxical relationship between BMI

cohorts of patients with RA, and patient demo-

[body mass index] and disease outcome in RA,

graphics such as DAS28 score and BMI were

they clearly support the benefit to all RA patients

recorded at the time of first visit.

of early and aggressive treatment.

Analyses found significant positive correla-

RA is a chronic autoimmune disease affect-

tions between disease activity (DAS28) and self-

ing up to 1 percent of the worlds population. It

reported disability (HAQ) scores and level of

S E P TE M B E R 2 01 4

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

19

and it may mean better protection of joints; and

obesity, as measured by BMI.

What implications do this have for treat-

it does offer some explanation as to why in the

ment in the clinic itself? asked Sparks. Well,

past weve seen an inverse association between

if our patients who are obese are consistently

increasing BMI and lower levels of radiographic

showing higher levels of disease activity, they

joint damage. However, further longitudinal work

may receive higher doses of more sustained

is going to be needed to ascertain the influence

DMARDS

anti-rheumatic

of a normal body composition on RA over time

drugs], which can be potentially harmful. On the

and also on the response to treatment in these

other hand, this could be beneficial for patients

patients.

[disease-modifying

S E P TE MB E R 2 01 4

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

20

European League Against Rheumatism (EULAR) Annual Congress,

June 11-14, Paris, France

Daily exercise may help suppress

inflammation in rheumatic disease
GREG TOWN

xercise has been shown to transiently suppress inflammation in an animal model of

rheumatic disease, bolstering evidence to support the theory that regular physical activity is
beneficial for patients with the disease.
Exercise can be a very potent therapeutic intervention to control inflammatory diseases, but
unfortunately today it is underutilized in clinical
practice, said study author Dr. Nicholas Young

Exercise is beneficial in mice models and may be a

potent therapeutic intervention for patients.

from The Ohio State University Wexner Medical

NF-kB activation was significantly inhibited in

Center, Columbus, Ohio, US. [In our study] we

mice that were exercised before and after LPS

hope to have displayed that exercise is a robust

injection, compared with those that were not.

systemic biological response modifier and that it

Furthermore, the anti-inflammatory response, in

can serve to regulate inflammatory responses.

terms of inhibiting NF-kB, was transient, lasting

Young and colleagues showed that exercise

only 24 hours after exercise.

attenuated local and systemic inflammatory re-

The effects of exercise are transient and they

sponses induced by a lipopolysaccharide (LPS)

are lost after 36 to 48 hours, which suggests that

injection, as indicated by inhibition of NF-kB (nu-

the greatest benefits would be achieved with a

clear factor kappa-light-chain-enhancer of acti-

daily exercise regimen, said Young.

vated B cell) levels in the lymphatic tissues of

transgenic luciferase mice. [Abstract OP0109]
LPS injection induced strong inflammatory

The researchers postulated that exercise acts

to inhibit NF-kB via the suppression of multiple
pro-inflammatory cytokines.

responses in the mice, which were strongest 2

As the inflammatory process in rheumatic

hours post-injection and accompanied by acti-

diseases is a major cause of disability, we are

vation of NF-kB, a protein complex that controls

excited to uncover the process by which exer-

genes involved in inflammation.

cise works on a molecular level to decrease this

Whole-body systemic analyses revealed that

inflammation, said Young.

S E P TE MB E R 2 01 4

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

21

Our results show the benefits that exercise

need for frequent exercise in order to cre-

could have in decreasing the great burden of

ate clinically significant results, concluded

rheumatic diseases. They also highlight the

Young.

Platelet-rich plasma injections

ineffective in tennis elbow, tendon
stimulation key
GREG TOWN

ltrasound-guided injections of growth factor-containing platelet-rich plasma (PRP)

are no more effective than saline injection in the

treatment of recently developed epicondylitis,
according to new research.
Epicondylitis is a painful condition that occurs
when elbow tendons are overworked, usually
as a result of repetitive wrist and arm motions.
Lateral epicondylitis (tennis elbow) is characterized by localized pain where the tendons of
the forearm muscles attach to the bone on the
outside of the elbow. Medial epicondylitis (golfers elbow) pain tends to be focused where the

Both PRP and saline injections performed similarly for

elbow pain.

tendons attach to the bone on the inside of the

A recent addition local injections of growth

elbow. In both conditions, the pain may spread

factor-containing PRP guided by ultrasound

to the forearm and wrist.

has been proposed as a novel therapeutic tech-

Currently there is no consensus on which

nique to optimize tendon repair.

of the large number of modalities employed to

However, a randomized double-blind study

treat epicondylitis, such as corticosteroid injec-

involving 50 patients with recent onset epicon-

tions, nonsteroidal anti-inflammatory drugs, or

dylitis showed no significant differences in pain

physiotherapy, is the most effective.

ratings between those treated with PRP injec-

tions and those given placebo saline injections at 6 and 12 months of follow-up. [Abstract
OP0013]

S E P TE MB E R 2 01 4

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

22

events were observed.

While PRP injections were shown to have
no inherent benefit in the treatment of epi-

Patients were treated with two ultrasound-

condylitis, what is exciting is that pain scores

guided injections every 4 weeks. A total of 22

in both treatment groups decreased signifi-

patients randomized to each treatment group

cantly over the course of the trial, said lead

completed the study. At 6 months, 54.7 percent

researcher Dr. Patrick Le Goux of Hpitaux Uni-

of PRP injection-treated patients had mean rela-

versitaires Paris Ile-de-France Ouest in Paris,

tive improvement in pain versus 63.6 percent of

France. The healing process is stimulated by

those receiving placebo, a non-significant differ-

the echo-guided injection of a substance and/

ence. However, the researchers noted that both

or by the own effect of the needle (needling);

treatment and placebo produced significant

the injections stimulate the process of tendon

reductions in pain scores at 6 and 12 months

repair through an irritation effect, a technique

when compared with baseline, and no adverse

known as prolotherapy.

Genotyping predicts disease severity,

outcome in RA
ELVIRA MANZANO

had a two-fold lower risk. [Abstract OP0190]

RA is a disease affecting the small joints of

llele variants at three new positions on the

the hands and feet, leading to destruction, de-

HLA-DRB1 gene can help predict the se-

formities and disabilities, said lead author Dr.

verity of rheumatoid arthritis (RA) as well as the

Sebastien Viatte of the Arthritis Research UK

response to treatment, studies have shown.

Centre for Genetics and Genomics, University

Positions 11, 71 and 74, which together define

of Manchester, in Manchester, UK. But once

16 haplotypes, have been shown to correlate

you get the disease, there is no way to predict

with disease severity and treatment response

which patient will develop severe disease and

(r2=0.93; p=0.037). Most notable of the find-

disability, or whether the disease will disappear

ings was that patients with amino acid valine at

spontaneously without any treatment.

position 11 on HLA-DRB1 had a four-fold higher

There are 101 genes identified to influence

risk of developing RA than the general popula-

the risk for RA. About one-third of patients risk

tion while those with serine at the same position

derives from environmental factors, while two-

S E P TE M B E R 2 01 4

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

23

thirds are considered genetic, said Viatte. The

and mortality in three independent cohorts

HLA-DRB1 gene is the most important gene as-

the Norfolk Arthritis Register (NOAR) which

sociated with the disease.

included 1,691 patients, the Early Rheumatoid

This major advance in genetics might allow

Arthritis Study (ERAS) of 421 patients, and the

stratification of RA patients at the onset of their

Biologics in Rheumatoid Arthritis Genetics and

disease to identify those at risk of joint damage

Genomics Study Syndicate (BRAGGS) with

and early death, and those who are more likely

1,846 patients. Further analysis showed that

to respond to anti-TNF [tumor necrosis factor]

on average, it would be necessary to treat 17

biologic therapy, he added.

patients with anti-TNF to see one patient re-

Previous studies have indicated that a group

sponding better based on the position of the

of alleles on the HLA-DRB gene referred to as

three-position haplotype. Sixteen haplotypes

the shared epitope had the strongest ef-

associated with the three gene positions were

fect on RA susceptibility. A more recent study

also able to predict all-cause and cardiovas-

showed that position 11 outside the shared epi-

cular mortality in the same group of patients.

tope was a better predictor of RA susceptibility.

However, more research is warranted in this

[Nat Genet 2012;44:291-296]

area to confirm the finding.

All three positions [11, 71 and 74] on the

Our findings provide the proof-of-principle

HLA-DRB gene now supersede the classical

that genetic markers of disease susceptibility

shared epitope, Viatte said.

predict disease severity, mortality and treatment

The researchers sought to determine wheth-

response, Viatte said. Within 5 or 10 years,

er HLA-DRB1 positions 11, 71 and 74 could pre-

genetic testing with a blood test will probably

dict radiological outcome, anti-TNF-response

enter rheumatology clinical practice.

S E P TE M B E R 2 01 4

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24

30th Annual Meeting of the European Society of Human Reproduction

and Embryology (ESHRE), June 29 July 2, Munich, Germany

Children born to women with fertility

problems face greater risk of
psychiatric disorders
CHUAH SU PING

treatment of women with fertility problems should

be aware of the small but potentially increased

hildren born to women with fertility prob-

risk of psychiatric disorders among the children

lems face an increased risk of psychiatric

born to women with fertility problems, said Dr.

disorders in adulthood compared with those

Allan Jensen of the Danish Cancer Society Re-

who were naturally conceived, a large cohort

search Center at the University of Copenhagen,

study conducted in Denmark suggests.

Denmark. The modest adverse health effects

According to the results, children born to

associated with infertility and fertility treatment

women with fertility problems have a 33 per-

should always be balanced against the physical

cent greater overall risk of any defined psychi-

and psychological benefits of a pregnancy.

atric disorder, including schizophrenia, neurotic

Most previous studies have not found a

stress-related and somatoform disorders, and

markedly increased risk of psychiatric disorders

mental retardation. The results were obtained

in childhood associated with maternal infertil-

from a registry study of 2,430,826 children born

ity or fertility treatment. However these results

in Denmark between 1969 and 2006, of which 5

are inconsistent, said Jensen. He noted that

percent (124,384) were born to women with reg-

these previous studies often had methodologi-

istered fertility problems, and 95 percent with-

cal problems including potential recall bias in

out. [Abstract O-066]

case-controlled studies, limited size and short

During the follow-up period, 170,240 children

were hospitalized for a psychiatric disorder.

follow-up periods, and incomplete or no control

for confounding factors.

The investigators found that the risk estimates

This is the largest cohort study to date with

between psychiatric disorders diagnosed dur-

the longest follow-up time, enabling assessment

ing childhood (0-19 years) and in young adult-

of risk patterns even in young adulthood, said

hood (20 years) were not markedly different,

Jensen. The registry-based data, he noted, pre-

indicating that the increased risks persist into

vented selection bias and limited loss during fol-

adulthood.

low-up. Researchers were able to adjust for vari-

Professionals involved in the diagnosis and

ous potential confounders and exposure status

S E P TE MB E R 2 01 4

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

25

was independent of patient recall. Despite these

offspring than the treatment procedures. It is

strengths, the study was not able to establish if

known, for example, that psychiatric disorders

the increased risk was associated with factors

to some degree have a genetic component,

related to the mothers infertility (genetic or bio-

said Jensen. Thus, he noted that it is likely that

logic) or to its treatment.

the damaged genes coding for psychiatric dis-

The exact mechanisms behind the observed

eases are over-represented in women with fertil-

increase in risk are still unknown but it is gen-

ity problems and, if transferred to their offspring,

erally believed that underlying infertility has a

could explain at least partly the increased risk of

more important role in adverse effects in the

psychiatric diseases in the child.

S E P TE MB E R 2 01 4

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26

30th Annual Meeting of the European Society of Human Reproduction

and Embryology (ESHRE), June 29 July 2, Munich, Germany

Hyper-responders to ovarian
stimulation face higher risk of low
birth weight babies and preterm births
CHUAH SU PING

ber of oocytes retrieved and live birth, following

IVF, said Sunkara. [Hum Reprod 2011;7:1768-

he risk of preterm births (PTBs) and low

1774] However, it had remained uncertain

birth weight (LBW) babies is significantly in-

whether response to ovarian stimulation has an

creased among women with a hyper-response to

association with adverse obstetric outcomes.

ovarian stimulation, according to research from

Theoretically, obstetric outcomes could be in-

the Assisted Conception Unit at Guys and St

fluenced by ovarian aging in poor responders,

Thomas Foundation Trust Hospital, London, UK.

ovarian dysfunction and high steroid levels in

We noted a strong association following

hyper-responders.

adjusted logistic regression, for each adverse

obstetric outcome PTBs and LBW babies
in relation to the number of oocytes retrieved,
said Dr. Sesh Kamal Sunkara. For each oocyte
retrieved, there was an increase in the odds of
LBW (<2,500 g) by 1.010, extreme LBW (<1,500

T
 here is a strong association
between the number of oocytes
retrieved and live birth,
following IVF 

g) by 1.014, PTBs (<37 weeks gestation) by

1.010, and extreme PTBs (<32 weeks) by 1.019.

For this study, the researchers analyzed

There was a significantly increased risk of

data from 402,185 IVF cycles and 89,202 birth

adverse obstetric outcomes among hyper-re-

outcomes. The data were obtained from the

sponders [>15 oocytes retrieved] compared

Human Fertilisation and Embryology Authority

with normal responders [4-15 oocytes]. Ad-

(HFEA) for all IVF cycles performed in the UK

ditionally, there was no significant increase in

from April 1991 to June 2008. The aim of our

adverse obstetric outcomes among poor re-

study was to explore whether there is an as-

sponders [3 oocytes] compared with normal

sociation between ovarian response to stimula-

responders, said Sunkara.

tion and obstetric outcomes following IVF, and

We have shown in a previous study that

to determine the relationship between the num-

there is a strong association between the num-

ber of oocytes retrieved and outcomes of LBW

and PTB following IVF.

S E P TE M B E R 2 01 4

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27

adapt ovarian stimulation regimens to prevent

In addition to confirming the association be-

excessive stimulation and hyper-response in

tween ovarian stimulation and adverse obstet-

patients undergoing fertility treatment. There is

ric outcomes, the researchers also found that

also a need for further research into whether

female causes of infertility (in particular ovula-

the ovarian dysfunction or the altered endome-

tory disorder and tubal disease) were impor-

trial milieu resulting from the supraphysiologi-

tant predictors of adverse outcomes.

cal estradiol levels underlies the adverse out-

Based on our results, it may be viable to

comes in hyper-responders.

Minimal association between fertility

drug use and cancer risk
CHUAH SU PING

present a mixed picture, with some showing

increases in risk, others decreases, and still

here is little evidence that the use of conven-

others showing no substantial associations,

tional fertility hormones for ovarian stimula-

said Dr. Humberto Scoccia from the University

tion in the treatment of infertility increases the

of Illinois at Chicago, Illinois, US. However, he

long-term risk of breast and gynecological can-

noted, most of these studies had small numbers

cers, according to results of a 30-year follow-up

with relatively short follow-up periods, and were

study. [Abstract O-192]

unable to control for other cancer predictors

The study was a retrospective investigation

including the indications for drug usage, such

involving 12,193 women who had been treated

as anovulation and endometriosis, which could

for infertility between 1965 and 1988 at five US

independently affect cancer risk.

sites. Evaluation was carried out via questionnaires and linkage to US death and cancer
registries, and a total of 9,892 women were
successfully followed for cancer outcomes until 2010. A total of 749 breast, 119 endometrial,

N
 o association with cancer risk
was identified except in those who
remained childless 

and 85 ovarian cancers were identified during

the follow-up period.

Thirty-eight percent of the study cohort had

Previous studies on fertility drugs and their

been treated with clomiphene, whereas 9.6

effect on breast and gynecological cancers

percent had been treated with gonadotrophins

S E P TE MB E R 2 01 4

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

28

(usually in combination with clomiphene). Scoc-

tion with cancer risk was identified except in

cia reported that the ever use of clomiphene

those who remained childless. Given that the

was not associated with any increased breast

majority of our women who received gonadotro-

cancer risk, except when subjects had used

phins also received clomiphene, it is likely that

the drug in 12 or more treatment cycles. Clo-

the increased risk among nulligravid women

miphene use was not significantly associated

reflects an effect on risk of their infertility rather

with either endometrial (hazard ratio [HR] 1.41,

than that of drug usage, said Scoccia.

95% CI, 0.98-2.04) or ovarian (HR 1.34, 95% CI,

Overall, the findings were reassuring, Scoc-

0.86-2.07) cancers, even with multiple exposure

cia opined. However, continuous monitoring is

treatment cycles.

needed because of the relatively young age of

Of the approximately 10 percent who had

been treated with gonadotrophins, no associa-

our study population and the later peak incidence of most of these cancers.

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S E P TE M B E R 2 01 4

R E S E A R C H R E V I E WS

29

Factors influencing awareness of the correlation between

physical activity and breast cancer prevention

espite considerable evidence of a correlation between physical activity and breast

cancer prevention, the extent to which women

are aware of this association remains unclear.
A recent study among Japanese women that
assessed their level of awareness reported that
sociodemographic variables, exposure to information, and knowledge about breast cancer
symptoms were significantly associated with
awareness.
The Internet-based cross-sectional survey
was completed by 1,000 Japanese women aged
2069 years (mean age 44.3 13.4 years) who
responded to questions regarding their awareness of the role of physical activity in breast
cancer prevention, knowledge of breast cancer
symptoms, risk factors and screening process-

level of knowledge of breast cancer symptoms

es, exposure to information on physical activity

(AOR 2.43, 95% CI, 1.753.36) were all positive-

and cancer, self-reports of physical activity level,

ly associated with awareness. Having children

and sociodemographic variables including age,

(AOR 0.65, 95% CI, 0.360.86) and a low level of

marital status, parental status, education level,

knowledge regarding breast cancer risk factors

employment status, and household income.

(AOR 0.30, 95% CI, 0.220.40) were negatively

The prevalence of awareness was 31.5 per-

associated with awareness.

cent (95% confidence level [CI] 28.634.4).

Marriage (adjusted odds ratio [AOR] 1.75, 95%

Miyawaki R et al. Awareness and correlates of the role

CI, 1.052.92), a high level of education (AOR

of physical activity in breast cancer prevention among

1.50, 95% CI, 1.012.22), exposure to informa-

Japanese women: results from an internet-based cross-

tion (AOR 2.11, 95% CI, 1.512.95), and a high

sectional survey. BMC Womens Health. 2014, 14:80.

S E P TE M B E R 2 01 4

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30

Atrophic gastritis may raise osteoporosis risk

in postmenopausal women

trophic gastritis decreases gastric acid production, resulting in hypochlorhydric con-

ditions that impair calcium absorption and may

increase the risk of osteoporosis in postmenopausal women, say researchers in Korea.
Their cross-sectional study investigated the
relationship between osteoporosis and atrophic gastritis in 401 postmenopausal women
older than 60 years of age who were undergoing medical check-ups at the Korea University
Anam Hospital in Seoul, Korea between March
1, 2007 and March 31, 2009. Dual-energy x-ray
absorptiometry was used to measure bone min-

to normal, osteopenic, and osteoporosis cat-

eral density, and atrophic gastritis was identified

egories. The odds of developing osteoporosis

endoscopically by atrophy and thinning of the

were increased among women with atrophic

gastric mucosa in the antrum and the body and

gastritis after adjusting for age, body mass in-

by well visualized submucosal vessels.

dex, triglyceride and high-density lipoprotein

When stratified according to the presence

cholesterol levels, alcohol consumption, and

of osteoporosis, more women with osteoporo-

smoking (odds ratio 1.89; 95% CI, 1.153.11).

sis had atrophic gastritis than women without

However, the researchers caution that their

osteoporosis (56.9 percent vs 43.1 percent,

findings need to be confirmed in large-scale

respectively). In addition, further stratification

prospective studies.

based on the extent of osteoporosis at the lumbar spine and femur revealed a linear relation-

Kim HW et al. Atrophic gastritis: a related factor for osteo-

ship between atrophic gastritis and allocation

porosis in elderly women. PLOS ONE 2014;9:e101852.

S E P TE MB E R 2 01 4

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31

Ovarian transposition following surgery preserves ovarian

function

varian transposition is often performed in

premenopausal women undergoing treat-

ment for gynecological cancers in an attempt

to preserve ovarian function. However, the benefits of this procedure have been unclear. Now,
a recent systematic review has found that ovarian transposition does indeed preserve ovarian
function with little risk of subsequent metastases
to the transposed ovaries.
The systematic review and meta-analysis
evaluated the outcome of ovarian transposition in 892 premenopausal women with gy-

ovaries. In addition, ovarian function was pre-

necological malignancy who required sur-

served in 94 percent of women who under-

gery with or without radiotherapy. Data were

went both surgery and brachytherapy (95% CI,

obtained from 24 observational studies iden-

79111) and 65 percent of women who also

tified by a systematic search of the Medline,

underwent external beam radiotherapy (95%

EMBASE, and Cochrane Library databases for

CI, 5674). The number of women who did not

articles published between January 1980 and

develop ovarian cysts or suffer metastases to

April 2014. A total of 428 women underwent

the transposed ovaries was 84 percent (95%

surgery alone, 143 had surgery plus post-op-

CI, 70101) and 100 percent (95% CI, 85118),

erative brachytherapy, and 321 had external

respectively, in the surgery plus brachytherapy

beam radiotherapy and surgery with or without

group and 95 percent (95% CI, 85106) and

brachytherapy.

100 percent (95% CI, 90112), respectively,

Among the women who underwent surgery

alone, 90 percent had preserved ovarian func-

among the women who also underwent radiotherapy.

tion (95% confidence interval [CI], 8299), 87

percent did not develop ovarian cysts (95%

Gubbala et al. Outcomes of ovarian transposition in

CI, 7997), and 100 percent (95% CI, 90111)

gynaecological cancers; a systematic review and meta-

did not suffer metastases to the transposed

analysis. Journal of Ovarian Research. 2014; 7:69.

S E P TE M B E R 2 01 4

F E ATU R E

32

National action plans urgently needed

to prevent and control hepatitis in the
Asia Pacific region
CHUAH SU PING

hronic hepatitis B and hepatitis C, together

with other forms of viral hepatitis, account

for over 1 million deaths per year in the Asia Pacific (AP) region, a death rate that is three times
higher than that caused by HIV/AIDS. [Lancet
2014; pii:S0140-6736(14)60844-8] Seventy percent of the worlds hepatitis-related deaths occur in the AP region. [Global Burden of Disease.
Available at www.healthdata.org/gbd. Accessed
on 29 July 2014]
Despite these alarming figures, a recent WHO
survey of ministries of health worldwide revealed
that only half of the countries surveyed in the region have a national action plan to prevent and

tion to Eradicate Viral Hepatitis in AP (CEVHAP)

control the spread of viral hepatitis. At the recent

and immediate past dean of the College of Med-

67th World Health Assembly, a new resolution

icine, National Taiwan University, Taiwan, about

on viral hepatitis WHA67.6 was unanimously

his views on hepatitis, the WHO Framework for

adopted, which urges member states to devel-

Global Action, and how the region can do more

op and implement coordinated national action

to fight viral hepatitis.

plans for preventing, diagnosing and treating

viral hepatitis. The WHO has also developed a

MT: Which country in the AP region reported

four-part blueprint the Framework for Global

the highest number or highest rising number of

Action as a guide for national governments on

cases of hepatitis?

effective ways to prevent and control the spread

Professor Chen: According to the Global Burden

of viral hepatitis.

of Disease Study 2010, seven of the 10 coun-

In conjunction with World Hepatitis Day on

tries with the highest number of deaths from

July 28, 2014, Medical Tribune (MT) interviewed

viral hepatitis per year are in AP. The top four

Professor Ding-Shinn Chen, chair of the Coali-

countries are China, India, Japan and Indone-

S E P TE MB E R 2 01 4

F E ATU R E

33

sia. It is difficult to ascertain how many people

veloped for other major disease areas include

are infected with viral hepatitis in every Asia Pa-

the Global Fund to Fight AIDS, Tuberculosis and

cific country because not all countries conduct

Malaria and Stop TB Partnership. The pharma-

routine surveillance. The WHO estimates that

ceutical industrys Accelerating Access Initiative

100 million people in Southeast Asia and 160

for HIV and Roll Back Malaria have established

million people in the Western Pacific live with

creative mechanisms for governments to work

chronic hepatitis B; 30 million people in South-

with the private sector, at-risk communities, pa-

east Asia live with chronic hepatitis C, but the

tient groups and healthcare professionals, sig-

number of people living with chronic hepatitis C

nificantly broadening access to diagnostics,

in the Western Pacific is unknown.

management and treatment of these diseases.

At CEVHAP, we urge the international donor

F
 unding is often the single greatest
obstacle to the adoption of
coordinated national response 

community to join the efforts of the WHO and

other organizations such as the Asian-Pacific Association for the Study of the Liver (APASL) and
associated national liver study associations, the
World Hepatitis Alliance and CEVHAP, to combat

MT: There are bound to be some challenges

viral hepatitis in the same way as HIV/AIDS, tu-

in developing national action plans for prevent-

berculosis and malaria were tackled.

ing, diagnosing and treating viral hepatitis, even

with the Framework for Global Action developed

MT: Why do only half of countries in the AP re-

by the WHO. What do you anticipate these key

gion have a national action plan despite 70 per-

challenges to be, and what are your suggestions

cent of the worlds hepatitis-related deaths oc-

for overcoming these barriers?

curring in the region?

Professor Chen: Funding issues present a sig-

Professor Chen:

nificant barrier to the ability of governments to

cussed, is a significant barrier. More generally,

implement lasting measures aimed at reducing

governments often lack the technical expertise,

the burden of disease, and funding is often the

resources and even evidence to justify the in-

single greatest obstacle to the adoption of coor-

vestments needed to confront viral hepatitis.

dinated national response.

Eight countries in AP still do not collect routine

Funding, which we just dis-

This is why we support resolution WHA67.6

surveillance data for viral hepatitis. This data is

in calling upon all relevant United Nations funds,

imperative for countries to develop national ac-

programs, specialized agencies and other stake-

tion plans.

holders to identify and disseminate mechanisms

Another reason is that because we now have

to support countries in providing sustainable

an effective vaccine for hepatitis B and hepati-

funding to combat viral hepatitis.

tis A, the perception of many people is that viral

Examples of successful funding models de-

hepatitis has been fixed. Sadly, that is not the

S E P TE MB E R 2 01 4

F E ATU R E

34

case. Where the hepatitis B vaccine has been

ideal situation, everyone with hepatitis B should

used to immunize newborn infants, it has cer-

have their liver function monitored every year to

tainly been effective in preventing new infec-

identify if liver damage is occurring. Again, with

tions, but we are living with a legacy of infection

hepatitis C, only a minority of people with the

that predates the vaccine. In the case of hepati-

virus needs treatment. There needs to be the

tis C, there is no vaccine.

infrastructure and access to health services for

people with viral hepatitis to identify whether

MT: What steps can governments take to change

they are at risk of liver damage, and whether

the approach from a Do we need a hepatitis

they require treatment.

program to When are we going to have one?

Professor Chen: All governments need to take action now to start to reduce and ultimately eradicate this terrible disease in our region. We be-

A
 ll governments need to take

lieve the WHOs Framework for Global Action

action now to start to reduce and

for the Prevention and Control of Viral Hepatitis

ultimately eradicate this terrible

infection is an ideal starting point for policy development and a measure against which gov-

disease in our region 

ernments can assess their current policies and

initiatives to address hepatitis.
Clinically speaking, treatment is not necesMT: Is treatment completely necessary? The best

sary for carriers because clinicians can now as-

currently available therapies achieve over 60

sess the risk of liver cirrhosis or cancer by the

percent long-term viral eradication, but only 20-

patients gender, family history of liver diseases,

30 percent of patients are believed to be at risk

liver function, HBV/HCV DNA level, etc. Those

of progression to cirrhosis and its complications.

who are judged to be prone to cirrhosis and

[Controversies in Hepatitis C Therapy. Available

cancer can then be treated. The treatment can

at www.medscape.org/viewarticle/443005. Ac-

effectively suppress HBV and prevent the devel-

cessed on 29 July 2014]

opment of the deadly liver disease mentioned

Professor Chen: It is not necessary for every

above. For HCV, the treatment is even more ef-

person with hepatitis B to be treated, but in an

fective.

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SEPTEMBER
8th International Liver Cancer
Association Annual Conference
5/9/2014 to 7/9/2014
Location: Kyoto, Japan
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Fax: (32) 2 743 1550
Email: info@ilca-online.org
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54th Interscience Conference
on Antimicrobial Agents &
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5/9/2014 to 9/9/2014
Location: Washington, D.C., US
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Tel: (1) 202 737 3600
Email: icaac@experient-inc.com
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European Respiratory Society
(ERS) International Congress
6/9/2014 to 10/9/2014
Location: Munich, Germany
Info: Secretariat
Tel: (49) 30 24603 220
Fax: (49) 30 24603 399
Email: ers2014registration@kitgroup.org
Website: www.erscongress.org
Asia Pacific Stroke Conference
2014
12/9/2014 to 14/9/2014
Location: Taipei, Taiwan
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Fax: (886) 2 8226 2785
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S E P TE M B E R 2 01 4

50th European Association for

the Study of Diabetes (EASD)
Annual Congress
15/9/2014 to 19/9/2014
Location: Vienna, Austria
Info: EASD
Email: registration@easd.org
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East Meets West 2014
25/9/2014 to 28/9/2014
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Diabetes Asia 2014 Conference
16/10/2014 to 19/10/2014
Location: Kuala Lumpur, Malaysia
Info: NADI
Tel: (60) 3 7876 1676, (60) 3 7876
1677
Fax: (60) 3 7876 1679
Email: enquiry@nadidiabetes.com.
my
Website: www.diabetesmalaysia.
com.my
9th World Stroke Congress
22/10/2014 to 25/10/2014
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stroke2014
8th Congress of the Asian Society
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14/11/2014 to 16/11/2014
Location: Colombo, Sri Lanka
Info: A/Prof Christopher Chen,
Department of Pharmacology, Yong
Loo Lin School of Medicine, National
University of Singapore
Tel: (65) 6516 3264
Fax: (65) 6773 0579
Email: phccclh@nus.edu.sg
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C A L E N DA R

36

IOF Regionals 5th Asia-Pacific

Osteoporosis Meeting
14/11/2104 to 16/11/2014
Location: Taipei, Taiwan
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Tel: (41) 22 994 0100
Fax: (41) 22 994 0101
Email: taipei2014@iofbonehealth.
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taipei-2014
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22/11/2014 to 25/11/2014
Location: Bali, Indonesia
Info: APDW2014 Congress
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20th World Congress on
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4/12/2014 to 7/12/2014
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Find out what these experts have to say about how to improve
patient care for osteoporosis and sarcopenia in Asia through
awareness building and the use of new therapies

Professor
Peter Ebeling

Professor
Serge Ferrari

Dr Edith Lau

Professor Bess
Dawson-Hughes

Widespread vitamin D
deficiency and low calcium
levels in Asians

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

Treatment plans for

post-menopausal women
with osteoporosis

How aging contributes to

sarcopenia and impaired
muscle function in the
elderly

How low levels of awareness

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

MIMS Video Series features

interviews with leading experts

For A 5-minute Update

Go to www.mims.asia/video_series

SCAN TO WATCH VIDEO

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S E P TE MB E R 2 01 4

A F TE R H O U R S

38

RADHA CHITALE

short stroll through Bangkok leaves no

doubt that Thais are obsessed with the

business of beauty.
Most people might love the idea of spending a day or a week dipping into a wealth
of spas for skin treatments and oil-slicked massages, but I tend to recoil from such manhandling.
I do, however, like the idea of bottling that
luxurious, pampered feeling and taking it home
with me to use at leisure.
Taking inspiration from their lush surroundings, a number of Thai companies are making
products with local ingredients that are creative and enjoyable. The soaps, oils and lotions
make liberal use of coconut and jasmine but
can incorporate more unusual ingredients like
bean, goat milk and spices.
Many of these companies promise locally
sourced, handmade products, often claiming
to be environmentally friendly in the process.

S E P TE M B E R 2 01 4

A F TE R H O U R S

39

While this can be difficult to verify,

a legitimate vendor would certainly
display a framed Good Manufacturing Practices (GMP) certificate from
Thailands Food and Drug Administration for cosmetics. False or misleading advertising is illegal.
My favorite shops were at JJ Mall
near Bangkoks Chatuchak Weekend Market. Limited by the 100
ml carry-on liquid restrictions on
planes, I picked up a few dry scrubs
and essential oils at Organique,
who make their products in Samut
Prakan province south of Bangkok.
Whether they deliver the benefits
they tout is questionable. But the
uplifting qualities of a good scrub,
a nice soak, and a hint of fragrance
through the day are not.

This mung bean scrub, which forms a paste in water,

smells as plain and clean as the raw beans and
appeals to the crafter in me as it can be stirred into
yogurt, honey, olive oil, or other mixing medium.

I picked up one essential oil in Moke, the

fragrant white flowers of the Water Jasmine
shrub, but I should have gotten them all.

S E P TE M B E R 2 01 4

There is no reason to panic, Mrs. Alcabassa.

Although there are certain indicators that
cannot be ignored!

Ah! What a beautiful morning to be alive!

It seems to reduce tension and

anxiety in most patients!

H U MO R

40

I used to be a kind, honest and overall, a nice guy.

Fortunately, they now have a patch for that!

You have the right to remain silent. Anything you

say can be used against you in the court of law
and you have an appointment with your doctor
next Tuesday at 10:15!

You seem to know something

about medicine. I like that in
a doctor!

Whoa! I havent even had

my coffee yet!

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