NHG boosts budget for healthcare training awards

Medical Tribune August 2008 SFXV
David Brill

An extra $2 million is being invested in further training for health professionals, the National Healthcare Group (NHG) announced recently.


This year’s Health Manpower Development Plan (HMDP) Fellowship Awards are to total around $6 million – an increase from last year’s figure of $4.1 million.

The awards, which are also supported by funding from the Ministry of Health (MOH), enable healthcare workers to undergo specialist training attachments at institutions in Singapore and overseas.

A total of 138 NHG staff – 50 doctors, 48 nurses, 35 allied health professionals and 5 administrators – were named as awardees by Mr. Michael Lim, Chairman of NHG.

“The HMDP allows our healthcare professionals to keep abreast with the best and most advanced in the world,” said Lim in a speech at the Institute of Mental Health (IMH).

“Medicine is a talent-intensive business so we must continue to invest in our people … we will use the HMDP awards to fill gaps in our healthcare system to meet the cluster’s long-term strategic plans and national priorities.”

Three new categories of award have been created, including the MOH HMDP Fellowship in Mental Health, which provides full sponsorship for further study in occupational therapy, clinical psychology and other areas within the field.

Ms Huang Wanping, one of the recipients, is presently a psychologist at the IMH having previously worked with the Singapore Police Force. The award will enable her to specialize as a clinical neuropsychologist by completing a 2-year masters at the University of Melbourne, Australia.

The other new categories are the MOH HMDP Award for Strategic Nursing Development, and the HMDP (Team Based) award, which was given to teams from National University Hospital, Tan Tock Seng Hospital and the National Skin Centre.

The HMDP was created in the 1980s by the MOH, but administration has since been devolved to NHG and SingHealth. The programme is responsible for inviting overseas expert to lead training programmes in Singapore, as well as sponsoring the nation’s healthcare workers to undertake further training abroad.

Mediterranean diet reduces diabetes risk

Medical Tribune August 2008 SFXV
David Brill

Following a Mediterranean diet – known to lower cardiovascular risk – can also reduce the chance of developing diabetes, Spanish researchers have shown.

The study, which was published in the British Medical Journal, followed 13,380 university graduates over a median period of 4.4 years and used questionnaires to rank their adherence to the diet on a scale of one to nine.

“Those who were highly adherent to this traditional dietary pattern exhibited a very low rate [of diabetes] and an impressive magnitude in the relative risk reduction of 83 percent,” said lead researcher Miguel Martinez-Gonzalez, Professor of epidemiology at the University of Navarra.

Interestingly, he added, people who adhered most closely to the diet were typically older with a higher prevalence of hypertension, smoking history and other risk factors for diabetes. The incidence among this group would therefore have been expected to be high.

“This may mean that the Mediterranean diet is highly protective against diabetes,” he said, but added that only 33 new cases were observed – a small number relative to the size of the study.

“This is fortunate for our participants indeed but this is a major limitation. We need further evidence from larger cohorts and trials,” he said.

The traditional Mediterranean diet comprises high amounts of olive oil, fruit, vegetables, nuts and fish, and relatively low amounts of meat and dairy products. The health benefits of the diet have been shown in various studies, including a randomized trial which demonstrated a beneficial effect on cardiovascular risk factors. [Ann Intern Med 2006 Jul 4;145(1):1-11]

Dr. Warren Lee, former Chairman of the Diabetic Society of Singapore, said that the study was interesting and comprised good quality data.

“I would certainly say this reinforces the old chestnut that one should take more fruit and vegetables and emphasize less on the meat,” he said.

It remains unclear at what point of adherence to the diet the benefits begin to accrue, added Lee, who is a pediatric endocrinologist in private practice and a senior consultant at KK Women’s and Children’s Hospital.

"This study was not able to show a threshold effect because it was designed to show that there was an effect in a relatively homogenous population of people who ate either more than the mean or less than the mean of certain foods.

“However it was heartening that a two point increase in a nine point score was able to reduce the incidence rate ratio – a measure of relative risk – by 35 percent, and that even those in the moderate adherence group had a significant benefit. This suggests that people trying to adhere to a healthy diet will be better off than those who do not even try,” he said.

Lee noted that the diet in Spain is rather different to that in Singapore, where food is frequently cooked using palm oil or pork lard rather than olive oil.

“Perhaps the next step is to see how we can incorporate elements of this diet into our food choices,” he concluded.

Doctors cure advanced skin cancer using T-cell clones

Medical Tribune August 2008 P12
David Brill

Researchers in the US have successfully treated a man’s skin cancer using laboratory-cloned T cells.

The team from the Fred Hutchinson Cancer Research Center in Seattle isolated and expanded autologous CD4+ T cell clones specific to the tumor antigen NY-ESO-1, and infused some five billion copies into a 52-year-old patient with refractory metastatic melanoma.

Computed tomography and positron emission tomography scans performed two months later showed that the patient’s tumor had completely regressed, and he remained disease free at 2 year follow-up.

His cancer had previously not responded to treatment with interferon alpha, interleukin 2 or local excision, and had spread to the groin, lung and left ilium.

Dr. Cassian Yee, who led the study, said that although the response was good in this case, more studies would be needed to confirm the efficacy of the procedure.

“This was just a small step, hopefully in the right direction,” he said, adding that the approach was only tested in patients with melanoma and the results should not be considered to apply to all cancers at this point.

The cloned CD4+ cells persisted in the patient’s blood for over 3 months without cytokine treatment – in contrast to CD8+ T cells which have been found to survive for less than 20 days without exogenous cytokines.

“Cell therapy represents a new vista in the treatment of cancer,” said Dr. Toh Han Chong, a senior consultant in the department of medical oncology at the National Cancer Centre Singapore (NCCS).

“It’s real – the fact that one patient had a long remission is great. But of course it doesn’t mean that if you treat a hundred patients all hundred will get a complete remission.”

A similar approach for patients with nasopharyngeal cancer is shortly to enter a phase II clinical trial at NCCS according to Toh, who is also an associate investigator in the laboratory of cell therapy and cancer vaccine. The trial is expected to last 3 years and will comprise 35 patients, each receiving 6 separate infusions of cloned T cells.

Writing in The New England Journal of Medicine, Yee and colleagues reported that T cells against other tumor antigens – MART-1 and MAGE-3 – were also found in the patient’s blood after the procedure, having been undetectable beforehand. This apparent extension of the immune response could explain why the tumor regressed completely despite the fact that only 50 – 75 percent of its cells expressed NY-ESO-1, the researchers said.

Nine patients were treated in all. Some others exhibited stabilization of their disease but it remains unclear why only one displayed complete regression, Yee said.

He added that T cell therapy could become more common in future, but at present the process requires very specialized equipment and training, and around 4 months is needed to grow the clones.

“Hopefully we can streamline that process a bit but it’ll never be like a drug that you can just take off the shelf,” he concluded.

Naltrexone reduces gambling urges and behavior

Medical Tribune August 2008 P13
David Brill

The opiate antagonist naltrexone could be an effective treatment for pathological gambling (PG), according to research from the University of Minnesota.

Participants who took the drug during an 18-week randomized trial had significant reductions in gambling urges and behaviour compared to those who took placebo, and displayed improvements in overall gambling severity and psychosocial functioning.

Naltrexone, which is typically used for alcohol and opiate dependence, was well tolerated at doses of 50, 100 and 150 mg/day.

Dr. Jon Grant, lead researcher of the study, said that the findings were very encouraging.

“We were excited because although we found that there was no difference in terms of response to different doses, the medication was still significantly better than placebo,” he said.

The study supports the use of medications as a tool to treat PG, according to Grant, who hopes that naltrexone will be offered routinely for future patients. He added however that there are many different options for treating PG, and that a combination of multiple interventions is likely to be most effective.

Ms. Elda Mei-lo Chan – supervisor at the Tung Wah Group of Hospitals Even Centre in Hong Kong which treats some 700 problem gamblers each year – stressed the importance of performing a holistic assessment before deciding on the appropriate treatment for each patient.

“Gambling is a very complex problem so you really have to look at the underlying causes of the behaviour,” she said, noting that medications can be effective for those whose urges are triggered by biological or neurological factors, whereas others may gamble to boost their self esteem or as a form of protest against problems in their life.

Chan added that patients receiving drug therapy should also receive some form of psychotherapy to help them fully understand the role of the medications.

“We’ve seen too many cases who come here and expect a couple of pills to solve everything. That’s not a realistic way of dealing with the problem – they really have to have the ability to improve relationships with their families and change their lifestyle so that they can still continue their work and their normal day-to-day life,” she said.

The trial involved 77 pathological gamblers, as defined by the Diagnostic and Statistical Manual of Mental Disorders. The positive treatment effect of naltrexone reached significance after 6 weeks. [J Clin Psychiatry 2008 Epub ahead of print]

Prior to enrollment, participants gambled for an average of 13.1 hours and lost US$535.54 per week. Having money was reported as the most common trigger for gambling urges, followed by stress, loneliness and advertisements.

Gambling behaviour and urges were assessed using a range of diagnostic tools, including the Yale-Brown Obsessive Compulsive Scale. Patients who improved during the trial said that they felt greater control over their actions and less of an impulse to act immediately on their urges, Grant said.

The study replicates and extends the results of previous studies into naltrexone for PG, carried out by the same group.

New partnership launched to accelerate TB drug research

Medical Tribune August 2008 P13
David Brill

A new collaboration was announced in Singapore last month that aims to facilitate the development of new drugs for tuberculosis (TB).

The 5-year agreement will allow information and ideas to be shared between the Novartis Institute for Tropical Diseases (NITD) and the Global Alliance for TB Drug Development (GATB), with a particular view to discovering drugs that work on resistant strains of TB.

“TB as an area is in desperate need of new drugs,” said Professor Paul Herrling, chairman of the board of the NITD.

“The essence of this is that we open our entire research protocol to the GATB. If we have a drug that looks promising for full development in TB, based on this agreement we can give them the exclusive license. It’s a very good thing.”

Shortening the duration of treatment is one of the major aims of the research, Herrling said. Current anti-TB drugs typically need to be taken for 6 to 9 months but resistance can develop when patients do not complete the course.

The project also seeks to find new drugs that are cheap to produce, easy to use, and do not interfere with HIV combination therapy.

The GATB – a not-for profit group which works with both private and public laboratories – is experienced in the later stages of drug development and in delivering new products to patients, Herrling said, whereas the NITD focuses on the early stages from the basic science through to proof of concept in humans.

“They really need a constant inflow of new compounds, and we are one of the suppliers. So it’s win-win in the sense that we produce what they want, and then they take our compounds and move them on beyond the stage that we would,” said Herrling, who is also a former vice president of the board at GATB.

TB was responsible for 1.7 million deaths in 2006, according to data from the World Health Organization. Almost half a million new cases each year are multidrug-resistant, with the highest-ever rates reported in 2008.

“One of the important changeovers [in drug discovery] is between the research part and what comes after,” said Herrling, adding that the new collaboration should speed up this part of the process.

“If you don’t do it well you lose a year or two or maybe even more at this interface, and that’s a bad idea because while you wait people are dying at the other end,” he concluded.

Chronic kidney disease: Asia’s ‘silent epidemic’

Medical Tribune August 2008 P14
David Brill


Reducing chronic kidney disease (CKD) should become a public-health priority, according to the authors of a large prospective study which found the national prevalence of the condition in Taiwan to be 11.9 percent.

This figure puts the condition on a par with smoking and obesity as a leading cause of death, the researchers wrote in The Lancet.

Awareness among the study population was low – just 3.5 percent of people knew that they had CKD.

The study, which followed 462,293 people over 13 years, also found that CKD is much more prevalent among lower socioeconomic groups, and that the regular use of Chinese herbal medicines carries a 20% increased risk for developing the condition.

“I think this is a silent epidemic,” said the study’s lead author Dr. Chi Pang Wen, from the National Health Research Institutes in Taiwan.

“It’s growing globally, and particularly Asians need to be even more concerned because of our fondness of taking medicine, including Chinese herbal medicine. The seriousness of this has not been well appreciated because people are only looking at the tip of the iceberg, which is the people on dialysis,” he said.

People with CKD were twice as likely to die from cardiovascular causes and 1.83 times as likely to die from any cause, the study found. Almost 40 percent of those who died were aged less than 65. [Lancet 2008 Jun 28;371(9631):2173-82]

The study highlights the importance of modifying risk factors such as hypertension, diabetes and smoking said Wen, who noted that the kidneys seem to be the earliest warning signal for vascular problems that may lead to cardiovascular death.

He called on the whole medical establishment to get involved with tackling the burden of CKD, beginning with the laboratories.

“When they report creatinine they need to have a formula to convert it into glomerular filtration rate (GFR). Without that conversion most Asian doctors are looking at creatinine which does not have as a high a level of sensitivity as GFR and cannot classify people into the 5 stages of CKD,” he said.

Wen added that the public should be encouraged to ask their doctor about their GFR value and whether or not they have proteinuria, which is an important warning sign for CKD.

Dr. Chan Choong Meng, Head and Senior Consultant in the Department of Renal Medicine at Singapore General Hospital, said: “This study shows that patients of a lower socioeconomic status are more susceptible to developing CKD. Unfortunately, they are likely to be unaware of the disease until a later stage.

“Early detection by screening and treatment for diabetes and hypertension will help reduce the burden of CKD, and early treatment will help in preventing and retarding the progression of the disease,” he said.

Chan added that the rates of CKD observed in the study are comparable to those previously documented for the US and Norway.

Diagnosing and managing osteoporosis in primary care

Medical Tribune August 2008 P15-16

Osteoporosis affects around a third of women aged 60 – 70 and two thirds of those aged 80 and above. The condition also affects men – approximately one in five of whom will suffer an osteoporosis-related fracture above the age of 50. Osteoporosis carries a significant burden in terms of hospitalization for fractures, and patients will typically experience increased morbidity, disability, and a reduction in independence.

Diagnosis

Osteoporosis is a silent epidemic, and overt signs are usually absent until a patient presents with a fracture. This is likely to be a fragility fracture caused by relatively low trauma – a sign that the bones have become weakened. Compression fractures of the vertebrae are a common presentation, while other types include Colles’ fractures of the wrist and hip fractures, both of which typically result from a fall.

There are several risk factors for osteoporosis that general practitioners (GPs) should be aware of, such as increasing age, frailty, a personal history of fractures and a family history of fractures (particularly on the maternal side). Loss of height is also common among patients, and suggests that the vertebrae are collapsing. Back pain may also be present – often signifying that the patient has an undiagnosed compression fracture.

It should also be noted that osteoporosis in men tends to have a later age of onset than in women. Consequently mortality from fractures is twice as high for men, so it is important that GPs retain a high suspicion for osteoporosis among their elderly male patients.

GPs can also encourage their elderly patients to use the Osteoporosis Self-Assessment Tool for Asians, which is applicable for post-menopausal women of Asian descent. This can help to identify patients at high risk, who can then visit their doctor for screening and further assessment.

The gold standard for diagnosis of osteoporosis is a bone mineral density (BMD) scan using dual energy x-ray absorptiometry, with osteoporosis defined as a T-score of minus 2.5 or lower. In the absence of any other cause, a fragility fracture can also be considered as a diagnosis for osteoporosis. Patients should also receive the relevant x-rays to fully document their fractures. It can be challenging for GPs to pinpoint osteoporosis in patients who have not experienced a fracture, as some patients might find the cost of the tests prohibitive. Access to BMD scanners can sometimes be problematic

Practice Guidelines

The Ministry of Health (MOH) in Singapore is currently revising its guidelines for osteoporosis, which were last published in 2002. The new version is expected to be available later this year. The Academy of Medicine of Malaysia also has its own guidelines for osteoporosis, the second edition of which was released in 2002.

Various guidelines and recommendations are also available from the International Osteoporosis Foundation (IOF) website, including IOF-endorsed guidelines published in 2008 by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). This comprehensive 30-page document covers the diagnosis and management of the condition in postmenopausal women.

Recommendations and other helpful documents for the secondary prevention of osteoporosis are available from the National Institute for Health and Clinical Excellence (NICE), UK.

Treatment

There are many factors to consider when treating osteoporosis, and it is important to decide carefully on an appropriate strategy for each patient before proceeding with treatment.
Drug treatments are available but the cumulative costs can be formidable. The first decision physicians should take after making a definite diagnosis of osteoporosis, therefore, is whether or not to treat the patient. This decision should be based on the patient’s 10-year fracture risk, which can be calculated using IOF guidelines. A 65-year old at low fracture risk, for example, might not warrant the same treatment approach as a high-risk 85-year-old. In some cases it may be best to postpone treatment following diagnosis, monitor the patient closely and review the decision at a later stage.

Before initiating drug therapy it is important to obtain a BMD scan. This will provide a baseline value for comparisons, so that the long-term efficacy of therapy can be monitored.

Bisphosphonates, such as alendronate and risedronate, are the first-line therapy for patients who do merit drug treatment. Doctors should make their patients aware that these drugs must be taken according to certain instructions. Tablets should be taken on an empty stomach first thing in the morning, and the patient should refrain from eating for an hour afterwards or consuming any caffeine-containing drinks or milk products in this time. Failure to do so can render the tablet ineffective – which may be an explanation in cases where BMD is not improving. Elderly patients may also forget to take the drugs, or take them but forget that they have done so and lie down shortly after, which can cause painful esophagitis.

Other drug treatments include strontium ranelate, raloxifene and parathyroid hormone injections (such as teriparatide).. Annual injections of zoledronic acid, a form of bisphosphonate, have also been shown to reduce the risk of fractures and the data in support of this option are promising. The injection can be expensive, however, and some patients might prefer treatments that spread the cost out over the year.

GPs should prescribe calcium supplements for patients who are deficient, which can be a common problem in Asian countries where dairy consumption is low. The recommended intake at different ages can be found in the guidelines. Boosting calcium levels can also serve as a prevention strategy, and GPs should also encourage the use of supplements in non-osteoporotic elderly patients who are at high risk.

Lifestyle management is also a key aspect of treating osteoporosis in the primary care setting. Ill-health can lower general nutrition, leading to further reductions in calcium levels, so a healthy diet should be promoted for all cases. Osteoporotic patients should be advised not to drink or smoke, and should also be encouraged to perform weight-bearing exercises at least three times per week for 50 – 60 minutes at a time in order to improve strength and co-ordination and reduce bone loss.

Disease management tools

Elderly patients living in the community have a roughly 30 percent chance of falling in a year, and fall prevention strategies are an important tool for reducing the risk of fractures among those with osteoporosis.

Falls typically result from a combination of several underlying causes. Risk factors such as poor gait, eyesight, and neurological comorbidities should be addressed where possible, which may require collaboration between different medical disciplines. Psychologically-altering medications such as antipsychotics and sleeping tablets can also increase the risk of falls, and may need to be adjusted accordingly.

Physicians may also need to consult with occupational therapists and physiotherapists, and in some cases might choose to encourage patients to make modifications to their home environment. Suggestions can include improving lighting, anchoring carpets and rugs, securing loose wires and applying non-slip mats to stairs and bathroom floors.

Further information on osteoporosis and home care solutions can usually be obtained from specialist centers and clinics, and GPs should refer their patients onwards for further advice and treatment where appropriate.

Conclusion

Managing osteoporosis in the primary care setting begins with an accurate diagnosis. GPs should remain vigilant for patients who have a history of fragility fractures or falls, and remember that men are also at risk for the condition. Once osteoporosis is identified, doctors should choose carefully from the range of available treatment options and select the strategy that is best suited to the patient.