Top 10 martial arts movies


10. Once Upon a Time in China

The film that kick-started Hong Kong cinema‘s kung-fu renaissance and launched Jet Li towards a future of substandard western action movies. Its subject was already well known to local audiences: Wong Fei-hung was a real person: a turn-of-the-century martial arts master and healer who’s become something of a folk hero. Like Sherlock Holmes or Robin Hood, he’d been portrayed many times before. Jackie Chan played him in Drunken Master, and a long-running Wong Fei-hung film series during the 1950s and 60s gave roles to the fathers of Bruce Lee and Yuen Wo-ping, among many others.

Transposed to 1990s Hong Kong, with the handover from British to Chinese sovereignty on the horizon, this story of a Chinese rebel fighting oppressive colonialist powers had extra resonance. Its British and American baddies are cartoonishly demonised, and the plot is often convoluted to the point of impenetrability, admittedly, but what this film chiefly provides is dazzling, colourful, kinetic, epic, pre-CGI spectacle. Director Tsui Hark, schooled in both the US and Hong Kong, fills the screen with movement and energy. The wire-assisted fight scenes – choreographed by Yuen Wo-ping, inevitably – are ingeniously staged. Earthbound reality is left far behind.

And Li is simply incredible. He’s got gravitas as an actor, but when he’s in action, he really takes some beating. He does it all: fighting with hands, feet, sticks, poles, umbrellas. He kills one baddie with a bullet – without using a gun. But Li is a gymnast, too, pirouetting and somersaulting across the screen with the agility of a cat. He’s surely the most graceful martial artist out there. Those skills come to bear in a jubilantly athletic final duel, which takes place in a warehouse conveniently full of bamboo ladders. It’s one of the most celebrated sequences in martial arts movies, and it leaves you wanting more, of which there is plenty: they made four sequels in the next two years. Steve Rose

9. Yojimibo

Yojimbo film stillAkira Kurosawa drew upon American pulp sources for Yojimbo’s plot, principally the Hollywood western but also Dashiell Hammett’s broken-city melodrama The Dain Curse. Here a lone, probably disgraced, certainly hungry samurai (Toshiro Mifune, the Wolf to Kurosawa’s Emperor) wanders into a town where two factions are in eternal conflict, glaring at one another from their matching headquarters on opposite sides of the town’s wide, western-like main street. Since each faction lacks a distinguished warrior with whose aid they might tip the balance of power in their favour, they each badly want the newcomer on their side, something the samurai figures out within moments, and exploits throughout the movie.

As the power games play out to their nihilistic, corpse-choked conclusion, Kurosawa demonstrates a mastery of his medium in almost every frame. His sense of spatial relations is beyond compare: panels in interior walls slide away to reveal whole exterior street-scapes and crowd scenes perfectly framed within the smaller new frame. Intimate conversations take place as a turbulent skirmish rages in the deep background center-screen, between the talkers’ faces in the foreground. And what faces! From the moronic warrior with the M-shaped unibrow and the giant wielding a huge mallet to Mifune’s increasingly battered countenance, sardonic, cynical and ever defiant, every single face is at once a landscape and an epic poem unto itself.

Along with all that comes Kurosawa’s furious visual energy, his virtuoso choreography of moving camera and bodies of warring men; and his talent for adding enriching layers of kinetic, elemental motion – rain falling, leaves or smoke blowing in the unceasing winds – to the violence already in play. Yojimbo led to the Italian A Fistful of Dollars, which in time completely remade the American western, completing a circle of international cultural exchange that foreshadows a give-and-take among international filmmakers that we take for granted today. John Patterson

8. A Touch of Zen

A Touch Of Zen film stillWe have A Touch of Zen to thank for Harvey Weinstein’s interest in Asian cinema; it was after Quentin Tarantino screened King Hu’s 1971wuxia that the mogul began a controversial spending spree in the east that led to his current controversial involvement with Bong Joon-ho’s Snowpiercer. It’s not hard to see why: Hu’s film is unusually epic for the genre, clocking in at over three hours, and made cinema history by being the first Chinese film to win an award at Cannes, missing out on the Palme d’Or but taking home the Technical prize.

A Touch of Zen is most notable nowadays as the template for Ang Lee‘s Crouching Tiger, Hidden Dragon, being the 14th century story of an artist, Ku, who encounters a beautiful woman living in a rundown house with her elderly mother. In true wuxia fashion, however, she is not all she seems, and so the story grows, until Ku realises that he is in the middle of a major dynastic war between rival factions. And as the story develops – effortlessly absorbing elements of comedy and romance – so does the spectacle, increasing in scale and scope in ways that would be unimaginable today.

It is these fight sequences that have endured, and although wuxia briefly fell out of favour soon after, it is easy to see Hu’s influence on the hit martial arts films of recent years. More so than Crouching Tiger, A Touch of Zen casts a long shadow over the films of Chinese director Zhang Yimou, whose House Of Flying Daggers directly references Hu’s film in its bravura bamboo forest sequence. But it is Hu’s deadpan sense of the grand that keeps this astonishing film fresh, with its themes of justice and nobility, shot through with a strange spirituality that earns the film its title in a sequence involving a pack of bouncing, kick-ass Buddhist monks.Damon Wise

7. The Raid

The RaidAs a breathless and brutal martial arts thriller shot in Jakarta and directed by a Welshman, The Raid would already have been worthy of note. That it is a film of precision and inventiveness, taking fight sequences into the realm of horror, slapstick comedy, even the musical, guarantees its place in action-movie history. The plot is as simple as its choreography is complicated. A police unit sets out one morning to seize control of a tower block in Jakarta that has fallen into the hands of a gang. But not just any gang: this mob has kitted out the high rise with sophisticated CCTV and public address systems monitored from a top-floor control room. The gang-lord, presiding over the CCTV screens, broadcasts a call to his tenants: “We have company. You know what to do.” He doesn’t mean put the kettle on and crack open the custard creams.

In the absence of much dialogue, the weapons do the talking: guns, knives, swords, hammers. A man receives an axe to the shoulder, which is then used to yank him across the room. A refrigerator doubles as a bomb. The gang’s most vicious member, Mad Dog (Yayan Ruhian, who also served as one of the film’s fight choreographers), acts as mouthpiece for the film’s philosophy. Casting aside his firearms, he explains: “Using a gun is like ordering takeout.” If that’s the case, Mad Dog would merit a fistful of Michelin stars.

Some of the fight sequences are enclosed claustrophobically in hallways where the only option is to use walls as springboards, Donald O’Connor-style. Others, such as a dust-up in a drugs lab, expand like dance numbers. Evans’s prime achievement has been to make a berserk adventure characterised by clarity. In contrast to most action cinema, the frenzy arises from the performers rather than the editing; no matter how frenzied things get, we never lose sight of who is karate-chopping the windpipe of whom. Ryan Gilbey

6. Ong-Bak

Ong BakHands and feet are one thing in martial arts; elbows and knees are quite another. And after seeing this Muay Thai showreel, you’d put money on Tony Jaa against any other screen fighter. Even in the scenes where Jaa isn’t fighting anyone at all, simply going through some moves, he’s awesomely formidable.

Ong Bak as a movie is fairly straightforward: city baddies steal a village’s Buddha head; a humble peasant goes to get it back, individually crushing each adversary with his bare hands in the process. That’s all it needs. Ong Bak’s prime objective is to say, “Can you believe this guy?” and with the added note that no special effects or stunt doubles were used, it more than accomplishes it. In fight after fight, Jaa unleashes moves that leave you thinking, “That’s gotta hurt”, if not “That’s gonna require major cranial reconstruction”. No holds are barred and few punches are pulled, but rather than brute violence, you’re left marvelling at Jaa’s speed, technique and pain threshold. The fights are skilfully staged, particularly an exhilarating, three-round barroom brawl that leaves no opponent or piece of furniture standing.

Jaa shows off his physical prowess in other ways, too, from an opening tree-climbing race to a Bangkok street chase that sends him along a hilarious assault course of cafe tables, market stalls, children, cars, trucks, sheets of glass and hoops of barbed wire. He’s almost too much to believe, and Ong Bak acknowledges our incredulity by frequently rewinding the action to show us Jaa’s moves in slow motion, as if to say, “Do you want to see that again?”. We do. SR

5. The Matrix

Keanu Reeves in The Matrix Cocteau imagined the mirror as a gateway to another world in his 1930 film The Blood of a Poet, and it’s a testament to the durability of this image that when it turned up again in The Matrix, it had lost none of its allure. The film clocks up a further debt in its plot, which proposes that what we perceive as reality is actually a cosmetic facade constructed to conceal a terrible truth about our existence. Neo, a computer boffin played by Keanu Reeves, is selected to bear the burden of enlightenment. Reeves’s blankness in the part is perfect, mainly because Neo is required to display only those skills and qualities that are downloaded into his brain. Required to master jujitsu, he is simply installed with the relevant computer programme. In no time at all, he is pulling off those tricks from 1970s martial arts movies, where a man can launch himself in a flying kick and somehow manage to prepare a cocktail, read a short novel and fill out his tax return, all before his feet touch the ground.

The film’s Cocteau-esque concept is harnessed to some X-Files-style paranoia, but it is the dazzling martial arts work that gives the film its special lift. The directors, the Wachowski brothers, were already having ideas above their station when they came up with The Matrix (their only previous film, after all, was the sweaty, claustrophobic thriller Bound). It was the martial arts choreographer Yuen Woo-ping who helped them reach the next level.

The movie’s fight sequences provide its purest source of pleasure for a number of reasons. First, the violence doesn’t come with redemptive overtones; it is played out for the thrill of the choreography, not the anticipation of injury or righteousness. Death is flippant, but it provides no moral kick. Second, the movie introduced a strange new effect, much copied or parodied since in everything from Charlie’s Angels to Shrek: a character freezes in midair while the camera circles the tableau like a computer imagining a 3D representation of a 2D image. When the camera has completed its movement, the physical motion of the scene resumes. Suddenly the humdrum vocabulary of the action movie has been extended before our disbelieving eyes. RG

4. House of Flying Daggers

House of Flying DaggersWatch the opening 20 minutes of House of Flying Daggers and it’s not hard to see why the Chinese picked its director, Zhang Yimou, to direct the opening ceremony of the Beijing Olympics. Even though the action unfolds within a reasonably sized brothel waiting room instead of a stadium, there’s all the elements that Zhang would multiply by the thousands in 2008: traditional Chinese music, dancing, swathes of brightly coloured silk cloth, drummers and, of course, martial arts. It makes for a magnificent spectacle that’s sets a high bar for the rest of the movie. Fortunately, there’s more dazzle to come in this follow-up to Zhang’s first wuxia film, Hero. Zhang’s 2006 Curse of the Golden Flower concluded the trilogy, but for many the romantic, operatic yet satisfyingly compact Flying Daggers represents the best of the three.

Set during the Tang dynasty, two police captains, Leo (Andy Lau, best known for the thematically-not-dissimilar Infernal Affairs trilogy) and Jin (hunky Takeshi Kaneshiro) are searching for the leader of the Flying Daggers, a counterinsurgency group. They suspect blind courtesan Mei (Zhang Ziyi) may be a secret member of the Daggers, so Jin, posing as a citizen, busts her out of jail and goes on the run with her, pursued by Leo and numerous expendable officers. Love seems to flower between Jin and Mei, but no one and nothing are as they seem here.

Although the fights are terrifically choreographed by Tony Ching Siu-tung – especially a bamboo-forest chase that tops Crouching Tiger, Hidden Dragon and a final mano-a-mano in the snow – judged against other classic martial arts films, Daggers is actually a little light on combat scenes. Indeed, the fighting is so stringently stylized it’s more like dancing with knives. No matter: the love story may be almost as schematic as the film’s rigorous use of colour, yet the acting is so powerful from the core trio that deep emotional depth is created seemingly out of nothing. Leslie Felperin

3. Police Story

Police Story film stillAlthough it was obvious at the time, it seems strange now that Jackie Chan was originally groomed by at least one Hong Kong producer as a successor to Bruce Lee, the lithe master of martial arts whose style was almost laughably serious in its grim-faced intensity. After a few tryouts in the genre, however, Chan took things in a much more comedic, but no less athletic route, which is why, after breaking out in the Yuen Woo-ping classic Drunken Master, the former stuntman found himself in Hollywood, adding light relief to The Cannonball Run in 1981.

Chan’s Hollywood career, however, didn’t pan out, and after a disappointment in 1985 with The Protector – a collaboration with neo-grindhouse director James Glickenhaus, perhaps not the most sympatico of all possible talents – Chan returned to Hong Kong to take matters into his own hands, directing and cowriting Police Story, in which he played a disgraced cop who is forced to go undercover and clear his name after being framed by drug barons.

Making a direct rebuttal of the Hollywood way of doing things (in his mind, sloppily and half-heartedly), Chan prioritised the fights and stuntwork, using the genre elements mostly as filler. Refusing to use a body double for every scene (bar one that involved a motorcycle), Chan began to earn his reputation as a fearless and pioneering action star. On this film alone, he was hospitalised with concussion, suffered severe burns, dislocated his pelvis and was almost paralysed by a shattered vertebrae. The resulting film was a huge hit and spawned five strong sequels. Seen now, it seems remarkably straight given what was to follow – the cartoonish Rush Hour series – although Chan certainly must have enjoyed the irony of being embraced by Hollywood for a film that is, essentially, a critique of everything it was doing wrong. DW

2. Crouching Tiger, Hidden Dragon

Crouching Tiger, Hidden DragonWhy is Ang Lee’s film Crouching Tiger, Hidden Dragon such a sublime experience? Perhaps because every bone in your body tells you it shouldn’t work. It’s a tranquil action movie. Whoever heard of one of those? And it’s a love story with a kick: a kung-fu kick. It begins with the theft of a fabled sword, the Green Destiny. As the sword is stolen, the camera takes flight along with the thief, for whom gravity is a restricting garment to be cast off at a moment’s notice. The warrior Yu Shu Lien (Michelle Yeoh) gives chase, skipping blithely across rooftops that glow silver in the moonlight. When the pursuit gives way to combat, the rule book of action cinema is not only discarded but sliced to ribbons. For viewers too young to remember, the shock of seeing a Sam Peckinpah shoot-out back when slow motion was an innovation rather than a nasty virus, then the sight of these warriors levitating calmly to nosebleed-inducing heights will provide something of that same liberating jolt.

The midair skirmishes of martial arts movies were brought to mainstream audiences by The Matrix, and Lee enlisted that film’s choreographer, Yuen Woo-ping (who later worked on Kill Bill and Kung Fu Hustle), to take that style even further. The resulting fight routines evoke Olympic gymnastics, break dancing and those cartoon punch-ups where one of the Tasmanian Devil’s limbs would emerge briefly from within a frantic cyclone. And if Yu occasionally steps on her opponent’s foot, she’s not fighting dirty – it’s just the only way of ensuring that the battle remains at ground level.

For all the finesse of the choreography, the action sequences would be superficial without the emotional weight Lee brings to the picture, notably in the largely unspoken tenderness between Yu and her fellow warrior Li Mu Bai (Chow Yun Fat). As a director he doesn’t differentiate between the way he shoots tenderness and violence. In his hands, a love scene can come to be brutal, with a man’s blood forming a fork across his lover’s breast as they embrace, while a struggle between opponents in the forest treetops, with the supple branches doubling as nests, catapults, rungs and bungee ropes, achieves a sensuous serenity. RG

1. Enter the Dragon

Enter the DragonBruce Lee purists may or may not agree that Enter the Dragon is his greatest film. But this is the one that has passed into legend: it was the colossal box office smash of 1973 and the most famous film of that unrivalled martial arts superstar who had died the summer before its release of a cerebral reaction to painkillers. He shared with James Dean the grim distinction of appearing posthumously in his most famous picture. After a career as a child star in Hong Kong cinema – almost the Macaulay Culkin of his day – and a spell on TV’s The Green Hornet, Lee exploded into action pictures that were simply so popular and profitable that Warner Brothers agreed to make Enter the Dragon, with Lee as star and coproducer: Hollywood’s first martial arts movie. Robert Clouse directed, and the script was by Michael Allin, who wrote the Isaac Hayes film Truck Turner. Lalo Schifrin composed the music.

Bruce Lee was possessed of extraordinary physical grace, balletic poise, lethal speed and explosive power. He was a master of kung fu, judo and karate, and is considered the spiritual godfather to today’s mixed martial arts scene. He was not a big man, and so his presence was better captured by the camera lens. Moreover, he had a delicately handsome, almost boyish face and had a charm and verbal fluency as he expounded his Zen theories of combat in interviews, something more like dynamic motivational philosophy than any fortune-cookie cliché. Lee had a presence and charisma comparable to Muhammad Ali, and that was perhaps never better captured than in Enter the Dragon. Perhaps only Jackie Chan now rivals him as an Asian star in Hollywood – and Hollywood has not shown much interest in promoting an Asian-American A-lister since Enter the Dragon.

Lee plays a Shaolin master who is recuited by British intelligence to enter a martial arts tournament undercover. This event is being run by a sinister megalomaniac called Han who is suspected of involvement in drugs and prostitution. Lee has a personal beef with Han, whose goons terrorised and attempted to rape Lee’s kid sister – she committed suicide rather than submit. He shows up at the island with a couple of American fighters: Williams, played by Jim Kelly, provides some Shaft-style street cred while Roper, played by John Saxon, is a playboy type who is close to the James Bond template. In truth, of course, it is Lee himself who is the James Bond, but he is no womaniser. Bruce Lee has a monkish purity and spirituality, with a laser-like focus on exposing Han – and of course kicking ass.

The look of the movie is exotic and extravagant, especially its inspired hall-of-mirrors showdown, with Lee sporting the weird, almost tribal slashes across his midriff. His strange, animal quavering cry and piercing gaze are entirely unique. But what makes Enter the Dragon outshine the rest is the serene, almost innocent idealism of Lee himself. In the opening scenes, Lee speaks humbly to the aged Abbot at his temple, coolly takes tea with the British intelligence chief Braithwaite, and interrupts their conversation to instruct a teenage boy in martial arts. When this young hothead is easily bested in combat, Lee says to him with inimitable seriousness: “We need emotional content – not anger.” It is the philosophy of this martial arts classic, and its unique star. Peter Bradshaw


HK confirms first H7N9 bird flu case

A vendor weighs a live chicken at the Kowloon City Market on 12 April 2013 in Hong Kong. Local authorities have stepped up the testing of live poultry imports from China to include a rapid test for the H7N9 "bird flu" virus

Hong Kong has suspended the import of live chickens from some China farms

  • Hong Kong has confirmed its first case of the new strain of the H7N9 bird flu in a domestic worker from Indonesia.

The worker, 36, recently travelled to Shenzhen in the mainland and came into contact with live poultry. She is in critical condition, officials say.

H7N9 has infected more than 100 people since it emerged earlier this year.

The case in Hong Kong is a sign that the virus may be spreading beyond mainland China, where most infections have been reported, and Taiwan.

The World Health Organization (WHO) had said there was “no evidence of sustained human-to-human transmission”, but also described H7N9 as an “unusually dangerous virus”.

At least 139 human cases of H7N9 have been confirmed, including 45 deaths, WHO says in a statement dated 6 November.

At least one case was confirmed in Taiwan in April.

Dr Ko Wing-man, Hong Kong’s food and health secretary, confirmed the territory’s first H7N9 case late on Monday.

He said that the patient “has a history of travelling to Shenzhen, buying a chicken, slaughtering and eating the chicken”.

“She is now in critical condition at Queen Mary Hospital,” he said, adding that four people in close contact with her were showing signs of flu-like symptoms.

Hong Kong is now on public health alert and has suspended the import of live chickens from some farms across the border with the mainland.

H7N9 is a type of influenza virus that normally circulates among birds and has not until recently been seen in people, the WHO says.

“There is no indication thus far that it can be transmitted between people, but both animal-to-human and human-to-human routes of transmission are being actively investigated,” the organisation adds.

Diabetes prevalence continues to climb in China.

Data from a survey of over 98,000 Chinese adults indicate that the prevalence of diabetes affects approximately 50% of the Chinese population, and only 25.8% of diagnosed patients are being treated.

“These data suggest that diabetes may have reached an alert level in the Chinese general population with the potential for a major epidemic of diabetes-related complications, including cardiovascular disease, stroke and chronic kidney disease in China in the near future without an effective national intervention,” the researchers wrote.

Researchers from the 2010 China Noncommunicable Disease Surveillance Group collected data from 162 study sites in the Chinese Center for Disease Control and Prevention’s (CDC’s) National Disease Surveillance Point System. According to researchers, measurements of HbA1c, fasting plasma glucose and 2-hour plasma glucose were collected from a nationally representative sample of 98,658 adults aged 18 years or older in 2010.

They found that the overall prevalence of diabetes was about 11.6% (95% CI, 11.3% to 11.8%) among the adult Chinese population (12.1% in men vs. 11% in women).

Further data indicate the prevalence of previously diagnosed diabetes was estimated to be 3.5% (95% CI, 3.4% to 3.6%) in the Chinese population (3.6% in men vs. 3.4% in women). Undiagnosed diabetes was estimated at 8.1% (95% CI, 7.9% to 8.3%) in the overall population (8.5% in men vs. 7.7% in women), according to data.

Moreover, the prevalence of prediabetes was estimated to be 50.1% (95% CI, 49.7% to 50.6%) in Chinese adults (52.1% in men vs. 48.1% in women).

The prevalence for prediabetes was greater among patients in older age groups (P<.001), urban residents, patients living in economically-developed regions and those who were overweight or obese, researchers wrote.

Data also demonstrate only 25.8% of patients with diabetes received treatment. Of those treated, only 39.7% had HbA1c levels less than 7% (40.7% in men vs. 38.6% in women), researchers wrote.

In an accompanying editorial, Juliana C. N. Chan, MD, FRCP, from the department of medicine and therapeutics at the Hong Kong Institute of Diabetes and Obesity, the Chinese University of Hong Kong Prince of Wales Hospital International Diabetes Federation Centre of Education, Shatin, Hong Kong, SAR, China, wrote that diabetes is a societal and health care challenge.

“To this end, government leaderships, partnerships, and community empowerment will be needed to create a health-promoting environment, encourage self-management, and strengthen the health care system to make health a reality,” Chan wrote.

Source: Endocrine Today.



One hundred years of congenital adrenal hyperplasia in Sweden: a retrospective, population-based cohort study.


Congenital adrenal hyperplasia due to 21-hydroxylase deficiency results in cortisol and aldosterone deficiency and is, in its most severe form, lethal. We aimed to assess the effect of historical medical improvements in the care of patients with this disorder over time and to assess the effects of neonatal screening in Sweden.


For this retrospective, population-based cohort study, we collected data for all known patients with congenital adrenal hyperplasia in Sweden between Jan 1, 2010, and Dec 31, 2011. Data sources included the registry at the Swedish national screening laboratory, patients identified via the Swedish neonatal screening programme, late-diagnosed patients reported to the laboratory, and patients who underwent genetic diagnostics or became known to us through clinical contacts. All known patients were included in a population-based cohort study of the distribution of clinical severity, genotype, sex, and the effect of nationwide neonatal screening.


We identified 606 patients with the disorder, born between 1915 and 2011. The CYP21A2 genotype (conferring deficiency of 21-hydroxylase) was known in 490 patients (81%). The female-to-male ratio was 1·25 in the whole cohort, but close to 1 in patients detected by the screening. We noted a sharp increase in the number of patients diagnosed in the 1960s and 1970s, and after the introduction of neonatal screening in 1986 the proportion of patients with the salt-wasting form of congenital adrenal hyperplasia increased in both sexes, from 114 (47%) of 242 individuals between 1950 and 1985 to 165 (57%) of 292 individuals between 1986 and 2011 (p=0·038). On average, five to ten children were missed every year before 1970. The non-classic form of the disorder was diagnosed more often in women than in men, which accounts for the female preponderance in our cohort.


Our findings suggest that, contrary to current belief, boys and girls with salt-wasting congenital adrenal hyperplasia were equally missed clinically. Neonatal screening improved detection of the salt-wasting form in girls as well as boys, saving lives in both sexes. The non-classic form was diagnosed more often in women than it was in men, leading to the female preponderance in this cohort.


Our findings show a substantial increase in the apparent incidence of congenital adrenal hyperplasia during the past century, with increases in line with improvements in diagnosis and treatment over time. The absence of a female preponderance has previously been interpreted as a sign of good medical care and diagnosis. However, our data show that both male and female patients with the salt-wasting form are missed clinically—even in a country such as Sweden with a developed health-care system—and that neonatal screening improves survival in both sexes. A large proportion of patients were not detected by neonatal screening. Non-classic congenital adrenal hyperplasia is diagnosed more often in women than it is in men, explaining the overall female preponderance despite the fact that male and female patients with salt-wasting congenital adrenal hyperplasia are diagnosed equally via screening.

To our knowledge, this study is the most extensive description of the changing apparent incidence of the different clinical forms of the disorder over time (panel). The sharp rise in the apparent incidence during the 1960s (figure 1) can be interpreted as the effect of not only the introduction of treatment with glucocorticoids in the 1950s, but also the concomitant increasing awareness of the disorder and its symptoms. Availability of a treatment generally results in increasing motivation among physicians to identify and diagnose a disease. However, in 1950, when glucocorticoids were introduced, there was only one active paediatric endocrinologist in Sweden, and little knowledge and awareness of congenital adrenal hyperplasia. Despite the obstacles, a few patients in the country were identified and started on glucocorticoid supplementation in the early 1950s. Laboratory diagnosis was difficult in both the 1950s and the 1960s, relying on measurements of urinary steroids. The amount of 17-ketosteroids was used as a measure of the level of androgens, and 17-hydroxysteroids as a measure of cortisol. Gonadotropins were measured with a mouse bioassay:extract from urine was given to prepubertal female mice and the uterine weight was subsequently measured as an indirect indication of the amount of gonadotropins.33


Research in context

Systematic review

We searched PubMed and Web of Science for research articles and reviews written in English with no restriction to year of publication. We used the search terms “congenital adrenal hyperplasia”, “21-hydroxylase deficiency”, and “CYP21A2”. We also searched the reference lists of retrieved articles. We identified no other studies describing the incidence of congenital adrenal hyperplasia related to the progress of diagnostics and treatment covering the past 100 years. The first effective treatment with glucocorticoids was introduced in the 1950s and improved patients’ survival. Mineralocorticoid treatment for patients with salt-wasting forms of the disorder was introduced shortly thereafter. Diagnosis has developed from clinical examination to laboratory markers and genetic analyses. Most publications report a skewed sex ratio, with more girls than boys diagnosed, in the prevalence of congenital adrenal hyperplasia, which is widely interpreted as more girls surviving the neonatal period.


Our findings show how medical development during the past 100 years has improved the survival of patients with congenital adrenal hyperplasia, first by the introduction of glucocorticoid and mineralocorticoid treatment and later with the introduction of neonatal screening. Our findings contradict previous ideas about the disorder: many have postulated that the female preponderance among patients with congenital adrenal hyperplasia is caused by missed diagnosis and increased mortality in boys. However, our data show that both male and female babies with the severe form of the disorder were missed clinically and that neonatal screening improved survival in both sexes equally. Non-classic congenital adrenal hyperplasia is diagnosed more often in women than in men, which accounts for the female preponderance in this cohort.

Since the 1950s, once diagnosis was made, treatment was still difficult. Treatment for congenital adrenal hyperplasia has changed little over time, with the exception of the introduction of mineralocorticoid treatment. The first mineralocorticoid, 11-desoxycorticosterone acetate, was given as sublingual tablets or subcutaneous implants that lasted for 3 months, at which point patients were at risk of adrenal crisis. Improved surgical techniques and more centralised surgical care have led to better surgical outcomes. However, these modern techniques also have shortcomings, such as strictures, reduced sensitivity, and impaired sexual function.153435

We detected no substantial decrease in the female-to-male ratio after the introduction of screening in our population. However, and more importantly, the proportion of salt-wasting forms of congenital adrenal hyperplasia increased substantially after the introduction of the nationwide neonatal screening programme. This finding should be taken into consideration when assessing the need for neonatal screening in a population. Specifically, the incidence of the salt-wasting form seems to be a more important and adequate measure for improvement of the situation for patients with congenital adrenal hyperplasia compared with the sex ratio alone. In the cohort of patients identified through the neonatal screening programme the female-to-male ratio was close to one. Mild forms of the disorder, presenting later in life and with no risk of salt loss, are detected more often in women. Hence, the female preponderance among the late-diagnosed patients is largely the reason for the high proportion of female patients in the whole cohort (figure 1), and there is a time lag before these patients contribute to the incidence. This occurrence explains the drop in apparent incidence as well as the equal sex ratio after the year 2000 (figure 1). The classification of patients by genotyping—81% had a known genotype—in combination with the nationwide coverage since 1986 made these conclusions possible.

The carrier frequency, and therefore the actual incidence of congenital adrenal hyperplasia has probably been stable over time because available data do not suggest a large global variance in the incidence of the salt-wasting form, with the exception of a few populations.3 On the assumption that all patients with salt-wasting congenital adrenal hyperplasia born after screening began have been diagnosed, the number of patients not identified in the pre-screening era can be reliably calculated because the birth rate in Sweden since 18th century is known (figure 3). Patients with the salt-wasting form of the disorder most likely did not survive the neonatal period whereas patients with the simple virilising form might have had adrenal crises during later infections,35 or might not have been diagnosed at all, as would also have been the case with patients with the non-classic form of the disorder. However, the estimated number of non-salt-wasting patients might be less reliable, because these individuals might have been missed in the screening and not all patients with a non-salt-wasting form of the disorder might have been reported to the registry. Additionally, the proportion of non-classic cases could have increased with the increasing immigration to Sweden since the late 1960s.

The apparent increase in incidence in the 1970s might suggest, to some extent, increased interest in the disorder and the fact that one of the investigators of this paper (AT) made a concurrent survey to identify all diagnosed patients. Neonatal screening could, in itself, have increased awareness of the disease and thereby also improved clinical diagnoses in patients with milder forms of the disease. More identified patients and an increased apparent incidence result in better awareness of the disease.

With screening in combination with the possibility of doing CYP21A2 mutation analyses, physicians no longer have to await electrolyte disturbances in a newborn baby to be able to assess the severity of their disease. Hence, the patients might escape the possible negative effects on brain development. The oldest patients mostly underwent CYP21A2 genotyping, which might be indicative of the fact that they are followed up more often at specialised clinics at university hospitals.

Some of the patients born before 1950 with congenital adrenal hyperplasia were initially assigned a male sex, with or without a hypospadias diagnosis. A physically detectable symptom, the virilisation of external genitalia, aided diagnosis and increased survival. In the 1950s, our knowledge of chromosomes and chromosomal determination of sex increased, and the analysis of Barr bodies became routine clinical practice in the 1950s.36 This development led to the general idea that all 46XX individuals with congenital adrenal hyperplasia should be raised as girls when the patients were diagnosed early.

In the middle of the 20th century, the focus was on the survival of the patients. With improved treatment, other aspects of the patients wellbeing can be addressed. The many patients with a known CYP21A2 genotype has enabled retrospective analyses of treatment outcomes in relation to disease severity—ie, cortisol deficiency and extent of androgen exposure.11,1334 The increased awareness of the psychological effects of prenatal exposure to androgens and disappointing surgical results in the more virilised patients, even using improved, modern techniques, have led to discussions about how treatment should be optimised and what sex the more virilised patients should be brought up as. The discussion about sex assignment has just begun.37

The integration of clinical work with molecular genetics and improved specialised care has been instrumental in improving the medical competence and the outcome for patients with congenital adrenal hyperplasia. Improvements in surgical and psychological care are some of the main challenges for the future.

Source: Lancet


Overfishing threatens quarter of key grouper species.


A quarter of grouper fish species face extinction or are near threatened because of overfishing and poor management of coral reef fisheries, and a further 30 per cent are so understudied there is not enough data to assess how threatened they are, according to a study.

Urgent conservation efforts are needed to tackle overexploitation and improve the management of these commercially-important fisheries, according to the study to be published in the June issue of Fish and Fisheries.

Most of the threatened and data-deficient species live in the developing world, where they provide crucial food and incomes, the study finds.

Groupers are found predominantly in the tropics and subtropics and they are estimated to be a multi-billion dollar a year industry, says the study.

Yvonne Sadovy de Mitcheson, lead author of the study and a professor at the University of Hong Kong, China, says: “Groupers are caught mainly by local fishermen who sell them to local markets or traders who may export or sell them to big businesses”.

But they are also caught by big industrial fishing boats, which remove them at unsustainable scales, she says.

Global catches of groupers rose by nearly 25 per cent between 1999 and 2009 to 275,000 tonnes a year, according to Food and Agriculture Organization figures in the study.

The studysets out major threats to the world’s 163 grouper species based on existing assessments using International Union for Conservation of Nature criteria.

It shows that 20 species, or 12 per cent of all grouper species, are at risk of extinction if overfishing trends continue, with a further 13 per cent near threatened.

The majority of these threatened species live in the Caribbean Sea, off Brazil and in the Coral Triangle, which consists of marine waters of Indonesia, Malaysia, Papua New Guinea, the Philippines, the Solomon Islands and Timor-Leste.

For 50 grouper species, there was insufficent data to even evaluate how threatened they are.

The study indicates that, while some management of grouper fisheries exists, challenges remain to ensure their protection and introduce long-term and species-specific monitoring.

“Groupers have slow life cycles, which means that they are among the more vulnerable types of species and easier to overfish than many other species,” Mitcheson says.

“Fishermen need to understand that the seas are not endless,” she says. “Source countries need to manage their reef resources, which are naturally limited and not very productive, with the food security of their people as a top priority.”

If this is impossible, nations could consider banning commercial exports of reef fish, she says.

John Randall, a senior ichthyologist at the Bernice Pauahi Bishop Museum, Hawaii, says that large-scale fishing by foreign nations causes major problems.

“Most alarming are the large fishing vessels from China — especially Hong Kong — that visit developing countries such as Indonesia to fish, often illegally, for groupers and other large fishes,” he says.

A study published online in Fish and Fisheries in March estimated that China alone underrepresents its overseas fish catch by an order of magnitude, especially in the waters off West Africa.

“The problem of underreporting catches or of illegal catches is very serious,” Mitcheson says, adding that it “undermines our understanding of fishery conditions and affects our ability to
manage fisheries”.


Fish and Fisheries doi: 10.1111/j.14672–979.2011.00455.x (2013)
Fish and Fisheries doi: 10.1111/faf.12032 (2013)

Source: SciVx



10 years on, the world still learns from SARS.


With eerie coincidence, a new coronavirus has emerged on the tenth anniversary of the SARS outbreak. Carrie Arnold looks at how the 2003 outbreak shaped disease surveillance and response.

In early 2003, Hong Kong virologist Malik Peiris thought several of his patients with severe pneumonia at Queen Mary Hospital were yet more human cases of avian influenza. Patients did not respond to antibiotics, and the severity of the illness was consistent with H5N1 influenza, which was then circulating in the area. Rumours abounded that a similar severe pneumonia was being found in nearby Guangdong, on mainland China, which only raised suspicions of a major influenza outbreak. Public health officials were bracing themselves for what they were sure was the next big pandemic.

They got their pandemic, but it was not influenza. It was an entirely new disease that would ultimately be called SARS. The disease outbreak showed the infectious disease community just how unprepared it was for a major pandemic.

SARS changed the spirit of things”, said Isabelle Nuttall, director of WHO’s the Global Capacities Alert and Response Unit. “It showed us that anything can happen anywhere.”

As an infectious disease physician at a major Hong Kong hospital, Peiris was one of the people at the centre of the SARS epidemic. His team identified and isolated the coronavirus that causes SARS, and his clinical expertise helped to control the hospital-based spread of the virus. Through hard work and international efforts led by physicians like Peiris and public health agencies like WHO, the SARS outbreak was halted less than a year after it began.

“We learned that any infectious disease outbreak anywhere in the world today could be a problem for the whole world tomorrow”, Peiris told TLID. “These lessons were reinforced by the influenza pandemic of 2009, although that turned out to be less severe.”

Perhaps one of the largest stumbling blocks to bringing SARS under control was an initial lack of transparency from Chinese authorities. When the first reports of a new pneumonia striking Guangdong began to emerge, the government did not step in to notify physicians, public health agencies, or other governments in the area.

At the time, WHO rules only required the reporting of four diseases: yellow fever, cholera, plague, and smallpox. Since the early SARS cases were clearly none of these, no government was under any sort of official obligation to notify WHO about them. Nuttall noted that this was a huge loophole of the existing health regulations. By the time SARS got too big to ignore, it had already spread far beyond the borders of Guangdong, making the disease much harder to contain.

Also missing was the laboratory capacity needed to detect and identify such emerging pathogens. Peiris noted that some of the areas where SARS hit the hardest—Hong Kong, Singapore, Toronto—had adequate biosafety facilities to run the appropriate tests. Other areas, like Cambodia and Vietnam, simply did not have that capability. If SARS had emerged in more resource-poor areas, he said, it could have taken a lot longer to bring the outbreak under control.

As a result of these poignant lessons, WHO officials decided to formally update the International Health Regulations (IHRs), a legally binding agreement. Public health officials had realised, even before SARS, that the IHR mandatory reporting requirements of only four diseases were inadequate. Arguments and ideas were continually bounced around but never enacted. In 2003, the SARS outbreak and ongoing low-level transmission of H5N1 avian influenza provided the impetus for WHO to act, Nuttall explained.

The new IHRs that were voted on in 2005 and began to be legally enforced in 2007 encapsulate many of the lessons epidemiologists and infectious disease physicians have learned during SARS. The IHRs form a sort of map or template of what countries and local communities need to do to be on the lookout for infectious disease outbreaks, and how they should respond when one of these outbreaks is detected. To start, the new IHRs give broader powers to WHO to investigate infectious disease threats and communicate them to the world, even without the support of local or national government. They also broaden the types of sources that WHO can use to begin an outbreak investigation.

Previously, a request for WHO involvement had to go through official government channels. In the case of SARS, the Chinese authorities did not request help or even notify WHO of the unusual cluster of pneumonia cases. WHO had heard about these cases through unofficial channels, but, because of stipulations in the older IHRs, they could not formally intervene, only watch and wait. Now, WHO can use these unofficial reports and even relevant newspaper articles as justification to intervene should it be warranted.

Improved laboratory capacity is also at the core of the new IHRs. The regulations require all countries to have infectious disease laboratories to test samples and do other routine surveillance tasks. “A lot of what we do to detect disease is really just boring old surveillance”, said John Oxford, a virologist working at Retroscreen Virology.

As boring as surveillance may be, Oxford noted, it is the key to identifying disease outbreaks from any source. Nuttall, too, cites this as one of the cornerstones of the new IHR. Although countries have until the end of 2013 to come into compliance with these regulations, many countries have asked for additional time to assemble the necessary resources.

Another power newly given to WHO in the revised IHR is their ability to do risk assessments and communication. One of the major reasons governments hesitate to inform the international community about disease outbreaks in their borders is the potential effect on trade and tourism. SARS was tremendously disruptive to business in Canada, China, and other parts of southeast Asia. People postponed or cancelled travel to these areas to avoid contracting the virus. Although these fears are certainly understandable, researchers know now that much of SARS transmission was centred in hospitals and health-care facilities, not by casual contact in everyday settings.

“It can be a delicate balance between sharing information and sparking panic”, said James Hughes (Emory University), former director of the National Center for Infectious Diseases at the CDC. “In today’s world, it’s not possible for countries to keep secrets for very long. It’s an incentive that favors early reporting.”

Although new diseases like SARS tend to have the splashiest headlines and garner the most media attention, most of the diseases that affect the largest numbers of people are the plagues we have known about for years, if not centuries. “By far, most of the outbreaks we see are from known pathogens”, Nuttall said. Still, this does not mean that an as yet unseen virus cannot cause major problems. 30 years ago, HIV was still a strange, emerging virus.

Some of the best ways to combat these diseases, emerging or otherwise, are not splashy and sexy, either, notes Oxford. During SARS, airports deployed heat sensors to measure fever of passengers. Though fancy and expensive, they did little to stop the spread of the virus.

“The best thing to do during any disease outbreak is ensuring people wash their hands. Although we know this, most of us still aren’t very good about it”, Oxford said. The money spent on this expensive equipment would have been better spent, in Oxford’s opinion, on sinks, soap, and running water, along with better personal protective equipment for health-care workers.

The H1N1 influenza outbreak in 2009 was perhaps the first main test of the new IHR. Officials from WHO and the larger public health community said that the new guidelines were successful. The Mexican government reported the outbreak quickly, and teams around the world worked together to track and respond to the virus.

“We also saw Mexicans being stigmatised, and then, with the term ‘swine flu’, the pork industry was stigmatised”, Hughes said. The ongoing risk of stigma and blame is one of the many needs for effective risk communication. When the public understands what is really going on, they can better respond to the actual threats from the disease and respond appropriately.

Other emerging viruses, like the coronavirus causing severe pneumonia in the Middle East and UK, continue to help test and refine the usefulness of the IHRs. Despite its eerie emergence almost a decade after SARS, this new coronavirus is only distantly related to is more notorious relative, and its much less efficient at spreading from person to person. Thus far, researchers have seen no large clusters of cases that indicate it will be a larger threat, although that could change at any time.

“It’s a recurrent lesson in infectious disease—expect the unexpected”, Hughes said.

Even as this story went to press, officials in China are reporting cases of a rare H7N9 avian influenza that has so far made 24 people ill, killing seven. Each outbreak, Nuttall says, helps the infectious disease community learn and better respond to future outbreaks.


Source: Lancet


Why Chinese Couples Are Divorcing Before Buying a Home.

Long queues of happy couples waiting to get married might be a common sight in Las Vegas. But lines of happily married couples waiting to get divorced? Only in China.

In major cities across the country last month, thousands of couples rushed to their local divorce registry office to dissolve their marriages in order to benefit from fast-expiring tax breaks on property investments for unmarried individuals. Local media reported long waits at registries in Beijing, Shanghai, Guangzhou and elsewhere as savvy investors sought to buy or sell a second home before the government introduced strict new regulations that would force married homeowners to pay hefty taxes on the sale of second properties.

The new regulations are designed to cool speculation in China’s feverish property market and are part of a package of measures that would require couples to pay up to 20% capital gains tax on the sale of second homes. But for determined investors, nothing gets in the way of a good bargain, and some quickly noticed that the 20% impost didn’t apply if the second home was bought before the couple were married — or after they got divorced.

China’s marriage law allows for divorce if couples simply sign an agreement to divorce, present themselves at the registry office and pay a fee of just $1.50. Weighed against the prospect of tens or even hundreds of thousands of dollars of profit from property investments, many couples are deciding the $1.50 charge is worth it.

According to media reports, in March the number of couples getting divorced in Tianjin, a large city on the eastern seaboard, soared to 300 per day — more than triple the normal amount. In Beijing, too, realtors reported a boom in divorcing couples seeking out new houses. “Half of the deals I made last month were cases where the couples were getting divorced,” a Mr. Jin, who works as an agent at one of the biggest realtors in Beijing, tells TIME. “These were all young couples between 25 and 35 years old, and all of them were looking to buy another house as an investment.”

As an emerging middle class accumulates wealth, more and more young families are finding that they have limited options to make good use of their money. With overseas investment options closed off by complex regulatory barriers, banks offering measly interest-rate returns on deposits and the stock markets on a never ending losing streak, there aren’t many attractive investment choices.

Some choose to invest in gold and other precious metals. Indeed, when gold prices fell sharply last week, shops in mainland China and Hong Kong quickly reported stock shortages and empty shelves. But China’s savvy purchasers have long had an affinity for putting their money into bricks and mortar, not least because property prices in most cities have soared over the past decade and continue to rise sharply.

With a seemingly endless supply of money flowing into the country’s property sector, and prices on a constant upward trajectory, regulators have long been worried about the frothy market giving rise to major property bubbles, especially in the most populous cities like Beijing and Shanghai. But it seems that canny investors are quick to spot ways around the cooling measures, hence the new vogue for divorce.

It’s not only profiteers who are choosing the divorce route. Many couples who simply want to trade up from their current home have realized that they can save tens of thousands of dollars by splitting up before making their next purchase. According to media reports, one couple in the southern city of Guangzhou, who already owned two apartments, saved $32,000 by getting divorced and selling one of their houses before buying another.

The divorce solution is extreme but it’s the kind of solution to which China’s put-upon middle classes have become accustomed. Civil-servant couples, for example, are subject to a particularly strict version of the one-child policy that would require them to give up their jobs if they had a second child. Some have decided to circumvent those rules by getting divorced and having a second child out of wedlock, registered under either parent’s name as a “first” child.

Of course, the country’s regulators have also taken notice of the long queues outside divorce registries and have acted to put a stop to the practice. In recent weeks, the government revised its regulations to increase the taxes payable by unmarried individuals selling a secondhand property, effectively cutting the most speculative investors out of the market.

Others, though, are still happy to break the knot, if only because they need not stay divorced for long. Realtor Jin advises his clients who are considering the process that they can be back in happy matrimonial bliss within as little as three weeks. “If you pay the full price in cash up front, the whole transaction can be completed in as little as 10 days — and even if you’re taking out a mortgage, it only takes about six weeks,” Jin says. “Once that’s done, you can go and get remarried right away.”



Before incubation, a coworking space for start-up conception.


It is a large “coworking” office finely tuned to the requirements of people who need space to dream about their start-ups, to be creative, to find like-minded individuals just to hash out ideas, to find partners, to take constructive breaks in a comfortable environment.

Coming here costs US$125 a month, a considerably smaller fee than coworking spaces in other metropolises. Members who use the space, called CoCoon, do not need to have a start-up, but they have to have a good idea or a useful skill, and be interested in interacting with other members to build a kind of supportive community that is said to be sorely lacking in Hong Kong.

CoCoon occupies the third floor of a shiny office building. Its main founder, Max Ma, who is in the jewelry retail business, owns the space.

He said he hopes it will help entrepreneurs build small and medium-size businesses that will create employment in Hong Kong — a city where giant conglomerates run most of the show and the wealth gap is the highest among all developed economies in the world, according to UN stats.

“This is my small contribution to Hong Kong,” said Ma, whose children Theodore and Erica Ma, also entrepreneurs, help oversee CoCoon. If leased out, the space’s monthly rent would be US$25,000, he said.

When CoCoon meets its goal of having 400 paying members, it is expected to recoup all costs — but Theodore Ma stresses that costs are beside the point; the most important factor for them is maintaining high-quality members, hosting useful events and helping start-ups that will be meaningful.

“Only when our entrepreneurs succeed in satisfying their customers and users will Cocoon truly
become profitable and meaningful in the long term,” he said in an e-mail.

Having opened its doors for less than two months, CoCoon is still working on screening and accepting members, or “tenants.” An application process helps identify who would have something to offer.

The group is looking for entrepreneurs, investors who would also act as seasoned mentors, and people who can offer skills like programming or graphic design. These varied members often come here looking for partners.

In space-tight Hong Kong, CoCoon is refreshingly bright, airy and open. The main working area, taking up half the floor, is sparsely populated with large desks — no cubicles in sight. A long row of metal lockers line one of the walls, high-school style. Small office-type rooms are in the back for making the occasional loud phone calls.

The other half of the space features a coffee bar, ping-pong table, foosball table, a meditation room with three bean-bag chairs (chairs are generally all over the place) and a library of start-up and tech-related books.

“We have foosball and ping pong, because watching fast-moving objects is supposed to provide good eye exercise,” especially for workers staring at computers all day, said Darren Yung, a manager at CoCoon.

Some of the wall space is covered in bright orange dry-erase boards, where ideas, inspiration and job openings get shared. The place’s other accent color motif is the techland favorite Android green.

But other than enviable toys and ample breathing room, CoCoon offers support for innovation, something that entrepreneurs says is rather deficient in Hong Kong.

Rayfil Wong comes here to work on his project, a children’s self-help book for the iPad. He laments that the government provides only scant funding for technology and is not doing enough to encourage innovation.

“There is a lack of motivation and constant fear,” he said, adding that individuals are reluctant to step out and do something innovative.

Tenants at CoCoon say Hong Kong’s obsession with its banks is, as usual, part of the blame. “Because of the booming financial industry, a lot of talent gets sucked into those sectors,” said Vicky Wu, a former banker who co-founder of ZaoZao, a crowd-funding website for fashion designers that is set to launch at the end of this month.

For example, Wu said, local graduates in programming make a beeline for operations and tech support jobs at banks. This makes it hard for start-ups to find programmers on a project basis. But CoCoon aims to fill some of that gap by helping to connect freelancers with small business people.

Wu and her partner, Ling Cai, were CoCoon’s first tenants. But their days spent here are nearing an end, as ZaoZao has been accepted into Science Park, a bona fide incubator that provides space — and much coveted government funding. Giving entrepreneurs the means to progress in their start-ups is one of CoCoon’s goals — and ZaoZao has become one of CoCoon’s first success stories.

Source: Smart planet