Fatty fish and fish oils could lower HF risk in men

Medical Tribune June 2009 P5
David Brill

Moderate consumption of fatty fish and marine omega-3 fatty acids may help to protect against heart failure (HF), a study of Swedish men has found.

Eating fatty fish once a week reduced the chances of developing HF over 6 years by 12 percent, while consuming around 0.3 grams a day of marine omega-3 fatty acids reduced the risk by 33 percent (adjusted hazard ratios 0.88, 95 percent CI 0.68 – 1.13; and 0.67, 05 percent CI 0.50 – 0.90).

The apparent protective effect did not grow stronger with increasing consumption, however. Eating more than moderate amounts, in fact, restored HF risk almost to that of men who did not consume any fatty fish or marine omega-3 fatty acids.

The researchers conducted food questionnaires in 39,367 men aged 45 to 75, and followed them up in inpatient and cause-of-death registries from 1998 to 2004. A total of 597 men developed HF in this time, 34 of whom died. [Eur Heart J 2009 Apr 21; Epub ahead of print]

“Our study shows that a moderate intake of fatty fish and marine omega-3 fatty acids is associated with lower rates of HF in men, but that the men did not gain a greater benefit by eating more of these foods,” said lead author Dr. Emily Levitan, a cardiology research fellow at Harvard Medical School, US.

“This study reinforces the current recommendations for moderate consumption of fatty fish. For example, the Swedish National Food Administration recommends consuming fish two to three times per week, with one of those portions being fatty fish. Similarly, the American Heart Association recommends eating fish, preferably fatty fish, twice a week,” she said.

Omega-3 fatty acids, which are found in fish oil, have been previously shown to reduce blood pressure, triglycerides and platelet aggregation, and to benefit heart rate and endothelial function. Consumption of fatty fish, such as salmon, herring and mackerel, has also been shown to confer cardiovascular benefits: one such study found that moderate consumption reduced the risk of coronary death by 36 percent and total mortality by 17 percent. [JAMA 2006 Oct 18;296(15):1885-99]

The reason for the U-shaped association between consumption and HF risk in the present study is unclear, said Levitan, although she speculated that men with poor health may be eating more fish in an attempt to improve their wellbeing.

“It will be important to replicate these findings in other populations, particularly those including women, as our study was conducted in men only,” she added.

Omega-3 fatty acids may also have a protective effect against age-related macular degeneration (AMD), a recent study of elderly Australians suggests. One serving of fish per week reduced AMD risk by 31 percent, with a similar magnitude observed for consumption of long-chain omega-3 polyunsaturated fatty acids. [Arch Ophthalmol 2009 May;127(5):656-65]

The OMEGA (Randomized trial of omega-3 fatty acids on top of modern therapy after acute myocardial infarction) trial, however, found that daily consumption of omega-3 fatty acids had no benefit for preventing sudden cardiac death after acute myocardial infarction, in a cohort of 3,851 patients with 1-year follow-up. The results were presented recently at the Annual Scientific Session of the American College of Cardiology.

End-of-life discussions reduce costs and relieve suffering

Medical Tribune June 2009 P7

David Brill

The decision to prolong life in advanced cancer patients presents an ethical, emotional, and financial challenge. Buying time can be costly, and a heavy legacy is often left for families and healthcare providers alike.

A new study suggests that physicians can play a major role in relieving this burden, simply by talking patients and families through their options and helping them to make plans in advance. Patients who had these end of life discussions received fewer aggressive interventions and had substantially lower medical costs, researchers found.

Economics aside, these discussions could also be in the patient’s best interests: the study found that high medical costs in the last week of life correlated to increased physical and psychological distress, and a worse quality of death. Moreover, survival was not significantly longer in patients who received aggressive therapies – raising questions as to whether the expense is justified.

Senior author Dr. Holly Prigerson said that patients ultimately have the right to choose, but that physicians can help to ensure that they make an informed decision.

“We’re not saying you should or you shouldn’t [prolong llfe], but you should at least realize what you’re buying with this more aggressive care. There is not improved quality of life,” she said.

“Whether they want to endure that pain is up to the patient to decide, but at least they should have the information to know that when they’re resuscitated, the likelihood that they’re going to survive an extra week really isn’t that much greater.”

Prigerson, director of the Center for Psychosocial Oncology and Palliative Care Research at the Dana-Farber Cancer Institute, Harvard Medical School, US, said that the study was born out of a belief among some oncologists that having end of life conversations would make patients “needlessly hopeless and depressed.” With data now showing that these discussions actually improve quality of life, she hopes that the study will bolster the confidence of physicians to address these “very difficult” subjects in future.

Singapore palliative care expert Dr. Cynthia Goh agreed that these conversations are important but stressed the need to approach them correctly. Physicians should listen to what patients and families want and guide them through their options, rather than pushing them towards a decision, she said.

“When talking about, for example, ‘do not resuscitate’ orders, the wrong way of doing things is to say: ‘do you want us to save your father or not?’” said Goh, director of the Lien Centre for Palliative Care at Duke-NUS Graduate Medical School, Singapore.

“What they’re talking about in this paper is a different kind of end of life conversation, which is certainly not initiated in the hospital corridor. It’s not about ‘do you want this or do you want that’ – really it’s a conversation to say what is important for the patient. People go bankrupt for this kind of treatment, so having the chance to reflect on whether it is likely to fulfill their life goals is a very good thing.”

Prigerson and colleagues interviewed advanced cancer patients from several US institutions, and followed them up until death. Of 603 patients, 188 (31.2 percent) reported having had an end of life conversation with a physician at baseline. [Arch Intern Med 2009; 169(5):480-8]

The mean cost of care for these patients was US$1041 (35.7 percent) lower than in those who did not have such conversations (P=0.002). Medical costs did not correlate to survival time (P=0.70) but were associated with worse quality of death, as assessed by caregivers and family members (P=0.006).

Another recent study led by Prigerson found that cancer patients who used religion to cope with the advent of death were more likely to receive intensive life-prolonging care. [JAMA 2009; 301(11):1140-7]

The explanation remains unclear but the effect appears to be driven by be a subset of patients who are not lifelong believers but rather turn to religion as death approaches, she said. Their new-found beliefs could therefore be a proxy for psychological distress, which manifests in a desire to remain alive for longer.

Goh, who is also honorary secretary of the Asia Pacific Hospice Palliative Care Network and co-chair of the newly formed Worldwide Palliative Care Alliance, said that the findings were very interesting but may not be applicable to Asian populations since the study patients were all American Christians. She added, however, that religion is an important factor in end of life decisions, and said that physicians should take these beliefs into account on a patient-by-patient basis.

Swine flu: The view from the Asia Pacific region

Medical Tribune June 2009 P7

Age no barrier to continued cervical screening

Medical Tribune June 2009 P9

David Brill

Cervical cancer screening should not stop at age 50, even in women who have had several all-clears in the past, new evidence suggests.

An analysis of national data from the Netherlands found that older women were just as likely to develop cancer after three negative smear tests as younger women.

Previous studies had found that pre-invasive disease is rare in well-screened over-50s, prompting calls for screening to be stopped at this age.

The Dutch study, however, focused instead on the incidence of full-blown cancers. It included data from 445,382 women aged 30 to 44 at the time of their third negative smear, and 218,847 women aged 45 to 54. [BMJ 2009 Apr 24;338:b1354]

After 10 years of follow-up the cumulative incidence of cancer was similarly low: 41 per 100,000 in the younger age group, and 36 per 100,000 in the older age group (P=0.48).

The findings suggest that age should not be the decisive factor for early cessation of screening in well-screened women, said lead author Dr. Matejka Rebolj. They do not, however, provide a definitive answer as to whether it will ultimately prove worthwhile to continue universal screening after three negative tests.

“We cannot really say with these data whether you should continue screening or not. However we can say that if you’re screening younger women, then in order to make your policy consistent you should continue screening women above the age of 50,” said Rebolj, a postdoctoral researcher at the University of Copenhagen, Denmark.

“The next logical step would be to do a proper cost-effectiveness analysis to determine whether this low absolute level of risk does warrant further screening. Until then we should encourage women to continue screening at the regular interval recommended in each particular country.”

Singapore oncologist Dr. Francis Chin praised the quality of the data, and said that the findings support Singapore’s policy of continuing screening up to age 69.

“This study confirms the importance of screening in the age group over 50 years old, because the risk of cervical cancer after several negative smears is similar in older versus younger patients,” said Chin, consultant radiation oncologist at the National Cancer Centre Singapore.

“The predilection of doctors has always been that screening and early detection is better than treating cancer in the later stages. These data confirm and validate this policy,” he said.

Singapore’s Health Promotion Board (HPB) agreed that the study supports the current guidelines of its CervicalScreen Singapore initiative, implemented in 2004. The program, which promotes screening every 3 years, will continue to focus on increasing its coverage of eligible women, said Dr. Shyamala Thilagaratnam, director, Healthy Ageing Division, HPB.

Several previous studies have proposed that cervical screening should stop at 50, notably a 1997 paper which found that only 1 percent of 23,440 previously screened over-50s had significant cytological abnormalities. The authors concluded that ending screening in this group could reduce anxiety and enable better allocation of resources to targeting higher-risk women. [Br J Obstet Gynaecol 1997 May;104(5):586-9]

The case against this argument, however, could be furthered strengthened by another recent paper, supporting the findings of the Dutch study. UK researchers, reviewing National Health Service screening records for 2 million women, found that two thirds of all the lesions detected in over-50s were found in women who had had previously had negative smears results. Discontinuation of screening would therefore lead to the majority of important abnormalities being missed, the researchers say. [Br J Cancer 2009 May 5; Epub ahead of print]

Singapore physician Dr. Siew Wei Fong concurred with the conclusion that screening should continue beyond the age of 50, in light of the recent evidence. She added that she does not expect any change in screening practices at the Singapore Polyclinics, where she is senior family physician.

Smokers more likely to drop oral contraceptives

Medical Tribune June 2009 P12
David Brill

Young women who smoke are more likely to stop taking oral contraceptives (OCs), a recent study suggests.

After 6 months of follow-up, only 26 percent of smokers were still taking OCs, compared to 46 percent of non-smokers (P<0.0001).

The study included 1,598 inner-city women aged under 25 – 198 of whom were smokers. After adjustment for confounding factors, smokers were 40 percent less likely to still be taking OCs (odds ratio 0.6; 95 percent CI, 0.4 – 1.0). [Contraception 2009 May;79(5):375-8]

“The take-home message is that smokers may be risk takers and thus more likely to discontinue contraceptives,” said lead author Dr. Carolyn Westhoff, professor of obstetrics and gynecology at Columbia University, New York, US.

The findings also serve as a reminder of the need to promote the right public health messages about smoking and OC use, say the researchers. Smoking while taking OCs is widely considered to be dangerous, but evidence so far is only conclusive for women over 35.

“The public health message and package labeling that birth control pills and smoking are incompatible is a bit over-simplified. While smoking is always a bad thing, the adverse interaction with OCs doesn't apply to our youngest patients,” said Westhoff. Pushing the same message to younger women could encourage them to quit OCs rather than quit smoking, she noted.

Study subjects were enrolled at three publicly funded family planning clinics. They reported smoking status at baseline, and OC continuation at 3 and 6 months. Twelve percent of the cohort were smokers.

“Whether public health messages or clinician messages about the risk of smoking and OC use are driving the excessive discontinuation rates seen in this study deserves further study,” the researchers wrote.

“In the meanwhile, these data indicate that young smokers may be a high-risk group for premature discontinuation of OCs. Clinicians need to clarify the appropriate health messages and find ways to support young smokers in avoiding pregnancy.”

The study is a secondary analysis of a previously published trial, which found that initiating OCs in the clinic, under observation, improved short-term compliance compared to a conventional, delayed start. [Obstet Gynecol 2007 Jun;109(6):1270-6]

In search of paradise

Medical Tribune June 2009 P18

David Brill

Halong Bay is a haven of spectacular natural beauty – once you run the tourist gauntlet to get there. David Brill seeks out the tranquility at the end of the conveyor belt.

The clues, in hindsight, were there from the start. Bundled from one minibus to another at 8 a.m., trying desperately to keep track of our luggage as it piled up on the sidewalk, it was clear that this trip was not going to be relaxing. We eventually squeezed into uncomfortable seats to be reassured by our unfailingly cheerful tour guide, over the death throes of the air conditioning system, that we were just a short trip away from one of the most beautiful places on earth. Suitcases loaded, we set off – joining an ever-lengthening convoy of vehicles on the bumpy pilgrimage to paradise.

This is the road to Halong Bay, where travelers flee the chaotic streets of Hanoi in search of the moped-free serenity of a cruise junk. One of Vietnam’s top attractions, the bay draws locals and tourists alike in their thousands all year round. In 1994 the area was designated a UNESCO World Heritage site – offering an extra level of attraction for the box-ticking Lonely Planet followers.

For most travelers, the experience begins at the hotels and high-street tour operators of Hanoi, where a disorientating selection of cruise packages is on offer to those who can successfully navigate a path through the traffic. Boats range from the basic to the seriously luxurious, and neither families nor students will find themselves short of choices. US$15 should cover a budget day trip, while 3-day, 2-night cruises start at around US$80 and extend anywhere up to US$600 for a deluxe double room at the top end of the scale.

The journey from Hanoi lasts around 4 and a half hours, complete with toilet stops at custom-built tourist traps. Weary-looking backpackers wander through aisles of paintings, wood carvings and conical hats, before rejecting it all in favor of an ice cream and a bottle of water. Many simply sit outside – eager to re-board the bus and reach the utopia they have been promised.

The prospects of relaxation and tranquility seem even more distant upon finally disgorging from the bus in the midday sun of Halong City. Tourists mill around in their hundreds, awaiting directions from their guides, who scurry frantically from office to boat and back, clutching papers, passports and money. Hawkers work their way through the increasingly restless crowd, selling t-shirts and hats to those who missed the earlier opportunity to buy them. Eventually the guides return to disperse the group, leading their followers into the armada of junks floating patiently in the harbor. Other boats lie further offshore, and some passengers must take a choppy connecting ride before finally putting their suitcases to rest.

For passengers on the luxury cruises, the tranquility of Halong Bay presumably begins as they step on board to be welcomed with a glass of champagne and a porter to carry their luggage. Those of us on the lesser boats had to wait a little longer, as we tucked into a disappointing lunch still moored against the backdrop of hotels and traffic. Our tour guide informed us that we had arrived and would shortly be free to relax, just as soon as we had visited a cave, gone kayaking, and explored a floating village. Definitions of paradise vary, but I had not expected it to run to such tight schedules.

It took some time yet to find the real Halong Bay, but there were no regrets upon arrival. As the boats escape the clutches of the harbor, it quickly becomes obvious why it draws so many visitors. A maze of limestone islands – some 1,600 in all – rises up from the sea, lining the horizon in every direction. Some are faceless, rocky outcrops, offering a surreal feeling of desolation, while others are overgrown with vibrant greenery that extends right down to the water. All shapes and sizes are present – from those resembling ancient volcanoes, to those no bigger than boulders poking their heads above water. One pair of miniature islands even appears locked in a stand-off, and is known either as the Fighting Roosters or the Kissing Rocks, depending on one’s romantic perspective.

The personal highlight of Halong Bay was to simply unwind and enjoy the beautiful surroundings. There are, however, several activities available for those seeking a distraction from the sunbathing. The caves were impressive, and there are many others to be explored if time allows. Kayaking is also enjoyable, offering the chance to find your own, quieter alcove if you have the inclination to paddle away from the crowd. Some islands have beaches – although a longer cruise may be required to reach those which can claim to be secluded – while swimming off the boat is also an excellent option when anchors are dropped for the night (a running jump from the top deck is highly recommended for those in a hurry to cool off).

For all its nooks and crannies, however, there are few places to hide in Halong Bay. The junks spread out as they leave the port, but the sheer weight of numbers ensures that they are never far apart. Moor up too close at night and you may even have trouble sleeping over the blare of music from next door. Add to this the regular appearance of small boats selling snacks, drinks and other tourist-friendly goodies, and you’ll begin to realize just how beaten the track really is.

Our overnight cruise ended in much the same spirit as it had begun: rushed off in a hurry as the cabin crew scrambled to prepare for the arrival of the next guests. Even the consolation hope of avoiding another disappointing meal proved unfounded, as we were herded into a restaurant at the harbor for a mass-produced set lunch, before embarking on the sweat-inducing return to Hanoi.

In spite of the prepackaged nature of the pilgrimage, I was left wishing that our trip had been longer. Halong Bay is spectacular, and truly deserving of its UNESCO acclaim, but it can scarcely be enjoyed in a whirlwind 24 hours. Take an extra day or two, explore the islands, and you should begin to shake the feeling that you’re doing the exact same thing as everyone else. Venture far enough from the mainland, and you might even find that tranquility you had hoped for.

Enter the dragon

Medical Tribune May 2009 P18
David Brill

It may have taken 2,000 years but dragon boating is finally going global. David Brill finds out what makes paddling so popular.

Four p.m. on a Saturday afternoon an unlikely-looking crowd begins to gather. Twenty year-olds chat idly with 50-somethings – locals mingle with expatriates. Some look ready for combat, sporting Rambo-style bandanas with oiled biceps to match. Others look ready for bed, reluctantly stretching uncooperative muscles and swapping stories of last night’s excess.

Ten minutes later their connection becomes obvious. Armed with large wooden paddles and bright red lifejackets they squeeze into long, narrow boats and take to the water. The coach shouts the command and they move off – arms rising and falling in unison as the individuals blend into a synchronized propulsion unit.

The team is paddling a dragon boat, and it is their love of the sport that brings them together each week. This group represents the British Chamber of Commerce – just one of the many teams which make up the now-thriving dragon boating community in Singapore. The local scene wasn’t always so healthy, however.

“Two years ago there were some weeks we couldn’t even put the boat in the water because there weren’t enough people to carry it,” says Mr. Paul Robinson, captain of the British team. “Then suddenly it shot up. Now we’re putting out three boats a week – around 50 or 60 people.”

There are currently some 7,000 regular dragon boaters in Singapore and the numbers continue to rise. From one-off corporate events through to teams that paddle at international level, there is a full spectrum of competition that makes the sport feel welcoming to all comers. This accessibility is one of the main forces behind its rising popularity, according to Mr. Jason Chen, a former member of the Singapore national team and now a professional dragon boat coach. What first began as a hobby at school has now developed into a full time career as sales and marketing manager of SAVA – a Singapore-based private company which aims to develop and promote the sport.

“Dragon boating is very easy to learn – it’s not a sport that requires years of training,” he says. “Satisfaction is high and there is that sense of teamwork, of trying to achieve a common goal.

“The sport is really growing. If you go into a shopping center now you’ll probably see someone walking around carrying a paddle. It’s becoming a trend that people will at least paddle a dragon boat once or twice in their lifetime, or be in a team for some time,” says Chen.

Dragon boating originated in China around 2,000 years ago and the country continues to dominate the scene today with some 50 million paddlers, according to the International Dragon Boat Federation (IDBF). The appeal of the sport, however, is rapidly spreading: there are presently over 300,000 dragon boaters in Europe and nearly 100,000 in the US and Canada. The IDBF, formed in 1991, now comprises 61 member countries, representing all the different continents and a wide range of socioeconomic backgrounds.

Hong Kong has one of Asia’s most vibrant dragon boat scenes and plays host to one of the world’s best-known events – the Stanley International Dragon Boat Championships. Up to 20,000 people turn up each year to compete, cheer on the teams and sip champagne aboard the flotilla of corporate junks that line the harbor.

“It’s a tremendous spectacle … like nothing I’ve ever experienced,” says Mr. John Pache, who coached the Royal Hong Kong Yacht Club men’s team to gold in last year’s Stanley tournament. He describes the win as an “amazing feeling,” but feels that for many of the new recruits to dragon boating, it’s the fun of taking part that counts.

“I think there are a lot of people who do dragon boating who don’t necessarily do a lot of other sports. It appeals to people who want to do something as part of a team but don’t necessarily want to do ball sports or a lot of running, or anything high-impact,” he explains. “People also like the social aspect of it. You can meet up with your friends and become part of a wide community that all turns up regularly, and enjoy all the events that go along with that.”

Pache believes the popularity of dragon boating will continue to rise naturally but says that much will depend on the sport’s ability to gain inclusion in the Olympic Games. The IDBF is working towards this goal but without definitive success so far. In the meantime the major international event remains the annual world championship, to be held this year in Prague, Czech Republic. Thousands have already registered for the event, and many more are expected to do so by the time the boats hit the water in August.

Back in Singapore there are plenty of opportunities to compete locally as well as internationally, with a constant spread of events throughout the year. Robinson and his team are currently training for the annual Singapore Dragon Boat Festival, to be held on the last weekend in June.

New starters to dragon boating may wish to dip their toe in the water with a training session, but it is the grandstand experience of these race days that will keep them coming back for more. The cheers from the crowd, the beat of the drums – everything combines to create a nerve-wracking yet exhilarating day out.

“It’s a hell of a shock to the system when the buzzer goes off,” says Robinson. “It’s all going to be over within minutes so you just go for it with everything you’ve got. You’re becoming tired with every stroke but you have to keep your mind focused and keep going. As soon as you cross the finish line you absolutely think you’re going to die. If you don’t then you haven’t paddled hard enough.”

For some, it is the camaraderie and social aspect that attract them to dragon boating; for others it is the intensity of a good upper-body workout. Robinson acknowledges all of these things, but ultimately it’s a simple desire to compete which drives him to take out his bandana every weekend.

“It’s a great rush of adrenaline and testosterone. I’m addicted to it. It’s like going to war. I’m friends with all the other captains but as soon as my foot gets in that boat I want to destroy them,” he says.

For more information on dragon boating, see: http://www.idbf.org/ and http://www.sava.com.sg/.