Monday, March 3, 2014 C9
HEALTH LAB REPORT ............................................ Jeanette Wang jeanette.wang@scmp.com
Illustration: Henry Wong
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f a disease is highly treatable, even curable, you’d think sufferers would be doing all they can to rid themselves of it. But people who have gout, the world’s most common form of inflammatory arthritis that often manifests in the big toe joint, don’t seem to be getting cured. Rates of gout are soaring in Britain, with about one in 40 affected – the highest incidence in Europe. But treatment remains as poor as it was in the late 1990s, according to a study published in January in the Annals of the Rheumatic Diseases. The study, which analysed long-term primary care medical records of about 4.5 million of the British population, found that between 1997 and 2012, the prevalence of gout rose by 64 per cent, increasing by about 4 per cent every year. Yet only a third of people with gout were being treated with urate-lowering drugs, a percentage that remained constant over the entire period. In Hong Kong, statistics on the prevalence of gout locally are scarce. The most recent data available was the Health Department 2000-2001 annual report, which stated a gout prevalence of 5 per cent to 6 per cent. Dr Eric Chak Hing-chung, a specialist in orthopaedics and traumatology at Central Consultative Clinic, says Hongkongers have a low level of awareness and insufficient knowledge on the complications or the deformity that can result from gouty arthritis. Patients only consult specialists in their acute stage. Historically, gout has been portrayed as a benign and even comical condition that is selfinflicted through overeating and alcohol excess, say a team of European researchers whose study in the Annals of the Rheumatic Diseases in 2012 reviewed existing papers on gout. This, they say, has led to a majority of gout patients receiving inadequate advice and treatment. “Suboptimal care and outcomes reflect inappropriately negative perceptions of the disease, both in patients and providers. Doctors often focus on managing acute attacks rather than viewing gout as a chronic progressive crystal deposition disease. Uratelowering treatment is
Toe
hold
Gout is on the rise, but if patients stuck to the treatment, the painful inflammatory arthritis could be controlled, writes Sunory Dutt
underprescribed and often underdosed,” say the researchers in their report. One of the oldest diseases described in medical literature, it was earlier referred to as “the king of diseases and the disease of kings” due to association with an overindulgent lifestyle and food habits. “There’s a misconception that gout can be managed with diet alone,” says Dr Chan Tak-hin, a specialist in rheumatology and chairman of the Hong Kong Arthritis and Rheumatism Foundation. “While dietary modification is important, many gout patients require proper medication to keep the disease under control. Without it, patients will continue suffering from frequent gout arthritis,” Chan says. Gout occurs when too much uric acid builds up in the body, causing crystals to form in joints,
making them inflamed and painful, and leading to disability due to pain and loss of joint function. Uric acid is produced during the breakdown of purine, a substance found in many foods including meat, offal, seafood, beans, peas, lentils, oatmeal, spinach, asparagus, mushrooms, yeast and alcohol. The condition mainly affects men between the age of 30 and
The more often an attack, the higher the chance of joint damage DR HANS SCHRADER, EXECUTIVE MEDICAL DIRECTOR AT MATILDA INTERNATIONAL HOSPITAL
60, or earlier if there is a history of renal or purine insufficiency. Women are also susceptible to it, especially after menopause when oestrogen loses its uricosuric effect (promoting the excretion of uric acid in urine). Most gout patients also have other pre-existing conditions like hypertension, high cholesterol, renal failure, obesity, coronary heart disease and diabetes. Apart from affecting the joints, there has been increasing evidence that links it with major cardiovascular diseases. It can also be insidious, with uric acid crystals depositing in the kidneys as stones, and causing renal damage. “The picture hasn’t changed; the common presentation is an overweight man occasionally with a family history of gout and often with recurrent attacks,” says Dr Hans Schrader, the
executive medical director at Matilda International Hospital. “As we see an increase in obesity, it is to be expected that gout problems will increase,” he says. There is consensus among local doctors that the prevalence of gout in Hong Kong may be increasing. Co-morbidities promoting abnormally high levels of uric acid in the blood such as untreated hypertension, obesity, diabetes, atherosclerosis (hardening and narrowing of the arteries), and chronic kidney disease, are on the rise. An urbanised lifestyle, unhealthy diet, excessive alcohol consumption, and medications such as thiazide diuretics (for hypertension), low dose aspirin and anti-rejection drugs are also contributing to its rise. Gout also runs in families, say University of Nottingham
scientists in a study published in December in the Annals of the Rheumatic Diseases. The scientists studied the entire 23 million population of Taiwan, where gout is most prevalent in the world, and found the risk of an individual with any first-degree relative suffering from gout is about twice that of the normal population. “Genetic factors contribute one-third in men and one-fifth in women,” says the study’s lead researcher Dr Kuo Chang-fu. The treatment of gout is relatively straightforward and involves a multidisciplinary approach. Non-steroidal antiinflammatory and prophylactic medications like Allopurinol are commonly prescribed in Hong Kong. Along with medication, the Department of Health advises gout patients to avoid foods high in purine, stop smoking and consuming alcohol, and to drink at least two litres of water a day to flush out uric acid from the body. Since gout most often is acute and painful, patients usually seek treatment immediately. However, convincing patients to take preventive measures to avoid recurrences is difficult. “I know quite a number of patients who probably could manage their disease without taking preventive Allopurinol, but whose lifestyle just does not allow a reduced dose,” says Schrader. “They’re reluctant to change their habits in diet, alcohol and weight management. “The more often an attack, the higher the chance of permanent joint damage, and not many patients are aware of this,” he says. Education about the condition and triggers associated with acute gout attacks is imperative. When patients can recognise the start of an attack and how to manage it, adherence to medication and lifestyle changes will greatly improve the management of their disease. “Patients with complications, such as severe cases not responding to conventional treatment or tophaceous [chronic] gout are better managed by specialists,” says Chan. “Specialists have the responsibility to provide adequate continuing medical education training on gout management for our general practice colleagues.” life@scmp.com
A better grip on survival A simple squeeze could be an important diagnostic tool in assessing strength and quality of life among critical care patients, new research from Canada’s Concordia University has found. In a study published in the journal Support Care Cancer, 203 patients fighting advanced-stage cancers squeezed a dynamometer with their dominant hand to measure their peak grip strength. “This measure is one of several to categorise patients according to the severity of their disease. It can help determine interventions they may need, whether clinical, nutritional or functional,” says lead researcher Robert Kilgour. Second-hand smoke exposure linked to pregnancy risk Even for women who’ve never smoked, exposure to second-hand smoke puts them at greater risk for pregnancy loss, including miscarriage, stillbirth and tubal ectopic pregnancy. The
increased risk is close to that seen among women who’ve smoked more than 100 cigarettes in their lifetime. The study, published online in the journal Tobacco Control, involved over 80,000 women and considered lifetime smoke exposure. Scientists transform skin cells into functioning liver cells Scientists at the Gladstone Institutes and the University of California, San Francisco, have found a way to transform skin cells into mature, fully functioning liver cells that flourish on their own, even after being transplanted into lab animals modified to mimic liver failure. This breakthrough, reported in Nature, offers new hope for treating liver failure. The method used reprogramming genes and chemical compounds to transform human skin cells into cells that resembled the endoderm, the cells that eventually mature into many of the body’s major organs.
Just close your eyes and flow to sleep ................................................ Elaine Yau elaine.yau@scmp.com Lo Siu-ching had suffered from severe insomnia for more than a decade. She tried endless sleepinducing methods, taking melatonin supplements, drinking a cup of hot milk before bedtime, counting sheep. You name it, she tried it, but all to no avail. To get a respite from the exhaustion that comes with severe insomnia, she sometimes took sleeping pills. “Though I still woke up in the middle of the night, the few hours of sleep under the influence of pills was better than nothing,” says Lo, 62. Worried that long-term use of sleeping pills would lead to dependence, she signed up to qigong classes six months ago to try to ease her sleeping problem. The exercises include tendon stretching, breathing techniques, and maintaining stationary postures for extended periods. “Although I still suffer from insomnia sometimes, I fell asleep more easily after doing qigong for a couple of months,” she says. Qigong is the ancient Chinese art of co-ordinating breath with a series of repetitive fluid movements which enables energy, or qi, to move through
the body, promoting mental and physical well-being. It has long been used by Chinese medicine practitioners to treat insomnia together with herbal medicine and acupuncture. The effects of practising qigong on insomnia patients will be studied clinically and scientifically for the first time in a study by Hong Kong University’s (HKU) Centre on Behavioural Health in October. Three hundred insomnia sufferers will be put into qigong and control groups to check the effect of the Taoist mental and physical exercise. The research participants will have blood tests before and after the qigong classes, which will run for eight weeks. Researchers will study the levels of brain-derived neurotrophic factor (BDNF) in patients, a protein found primarily in the
We integrate Chinese wisdom with Western psychotherapy principles PROFESSOR CECILIA CHAN, HKU
brain which is capable of regulating the development of neurons. Variations in BDNF levels have been linked with mental illness, developmental delay and neurological diseases. Cecilia Chan Lai-wan, a professor in health and social work at HKU, says practising qigong can speed up the flow of energy and blood circulation and help ease insomnia. “In the concept of Chinese medicine, insomnia can be caused by blocked meridians (the pathway system through which qi flows). Qigong can help remove the blockages so that qi and blood can flow to the internal organs.” Dr Yuen Lai-ping, chairman with the International Association for Health and Yangsheng, which is collaborating with HKU on the study, says qigong can help attain balance between yin and yang, which in turn can help with insomnia and mood disorder. “The qigong exercise regime is called Five Elements and
Balance Qigong which consists of five simple exercises involving kicking legs and whole-body relaxation,” Yuen says. “It’s also mental training, as it requires concentration and regular breathing rhythm that helps the practitioner achieve a focused mind. “We have done studies before
which show that qigong can help lessen the chronic exhaustion and depression symptoms of those suffering from chronic fatigue.” Since 2001, the Centre on Behavioural Health has developed an integrated approach which involves the body, mind and spirit to boost people’s holistic wellbeing, says Chan. “We integrate traditional Chinese wisdom with Western psychotherapy principles. The integrated approach incorporates mindfulness practice, acupressure techniques and easyto-learn physical exercises like qigong,” she says. “It can boost people’s flexibility and resilience in dealing with life adversities. Our studies have shown that the integrated approach helps improve mood and quality of life and reduces stress which is among the major causes of insomnia.” Health Department figures show that about 20 per cent of the population, or around 1.4 million people, suffer from sleep disturbance.
While Western doctors prescribe sleeping pills, or refer patients to psychologists or psychiatrists for cognitive behavioural therapy or psychotropic drug intervention, Chinese doctors use herbal medicine and acupuncture as the first line of treatment. Zhang Shiping, associate professor and expert in acupuncture and neuroscience with the Baptist University’s School of Chinese Medicine, says a Chinese medicine doctor will first find out the underlying mechanisms for insomnia. “We look at the person as a whole and look at which organ in the body is in imbalance. For example, insomnia is commonly related to four organs: heart, spleen and liver and gall bladder. For heart, spleen and gall bladder, we often see deficiency of the chi of these organs. For liver, it can be caused by the chi stagnation of liver, which can cause a fire,” Zhang says. “Deficiency in kidney due to ageing will also cause insomnia. You see lots of elderly people suffering from insomnia because their kidney functions are weakening due to ageing.” It’s important to know the differences in how Chinese and Western medicine define deficiency in organs, Zhang says. “When Chinese medicine talks
about kidney, spleen and heart, etc, we are referring to a group of functions rather than the actual organ. I have patients who were told that their insomnia is due to deficiency in [a] kidney. “They then go to Western medical practitioners to have their kidney function tested. But the results turn out to be normal. They are very puzzled as to which practitioner is correct. “In this case both are correct. It’s because Chinese medicine is talking about the function of kidney, which includes the growth of the individual, the reproductive function of the individual, his urinary function and also the functions in sex hormones and growth hormones. Herbs with different properties will be prescribed to treat the imbalance of these organs, Zhang says. “With acupuncture, we can select different acupuncture points to adjust the balance of the energy within all these organs. And qigong, meditation techniques, can also help.” Multiple approaches are needed to cure insomnia. Lifestyle changes such as doing exercise, taking a hot bath before bedtime and avoiding caffeine after midday, can help, Zhang says.