Download May 2012

May 2012
www.medicaltribune.com
Dramatic blood sugar control
with gastric surgery
INDONESIA FOCUS
Bahaya konsumsi gula
tambahan berlebih
IN PRACTICE
Managing acute otitis media:
Strategies for GPs
UROLOGY
NEWS
Odor may help signal UTI
in children
Bergamot orange a natural
supplement
2
May 2012
Dramatic blood sugar control with
gastric surgery
Radha Chitale
G
astric surgery controlled blood sugar
better than intensive medical therapy
among obese type 2 diabetics, according to
the STAMPEDE trial, the results of which
were presented at the 61st Annual Scientific
Sessions of the American College of Cardiology meeting in Chicago, Illinois, US.
Patients who underwent Roux-en-Y gastric bypass surgery or sleeve gastrectomy
achieved HbA1c control below 6 percent
within a year in 42 percent (P=0.002) and
37 percent of cases (P=0.008), respectively,
compared with 12 percent who received intensive medical therapy alone. [N Engl J Med
2012 Mar 26. Epub ahead of print]
“Despite improvements in pharmacotherapy, fewer than 50 percent of patients with
moderate-to-severe type 2 diabetes actually
achieve and maintain therapeutic thresholds,
particularly for glycemic control,” said researchers from the Cleveland Clinic in Ohio,
US, Veterans Affairs Boston Healthcare System and Brigham and Women’s Hospital in
Boston, Massachusetts, US.
“Observational studies have suggested
that bariatric or metabolic surgery can rapidly improve glycemic control...”
The trial randomized 150 obese patients
(mean age 49 years, mean body mass index
36 kg/m2, mean HbA1c 9.2 percent) with uncontrolled type 2 diabetes to receive intensive medical therapy alone, medical therapy
The STAMPEDE trial showed that gastric surgery
significantly lowered HbA1c levels compared with intensive
medical therapy alone in obese patients with type 2 diabetes.
plus Roux-en-Y gastric bypass surgery or
medical therapy plus sleeve gastrectomy.
Intense medical therapy followed the
guidelines of the American Diabetes Association and included lifestyle counselling,
weight management, and drug therapy.
Patients randomized to surgery experienced significantly more weight loss compared with those receiving medical therapy
after 12 months (-29.5 kg gastric bypass, -25.1
kg sleeve gastrectomy, -5.4 kg medical therapy, P<0.001 for both) and lead author Dr.
Philip Schauer, of the Cleveland Clinic, said
this, more than anything else, was the likely
driver for glycemic control.
Mean HbA1c was 6.4 percent in the gastric bypass group (P<0.001), 6.6 percent in
the sleeve gastrectomy group (P=0.003) and
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May 2012
7.5 percent among patients receiving medical therapy.
Patients who underwent surgery also significantly reduced or halted use of glucose
control and cardiovascular medications.
“Reductions in the use of diabetes medications occurred before achievement of maximal weight loss, which supports the concept
that the mechanisms of improvement in diabetes involve physiologic effects in addition
to weight loss...” the researchers said.
No deaths or life threatening complications
occurred although four patients required a
second surgery for complications.
In an accompanying comment, Dr. Paul
Zimmet, Baker IDI Heart and Diabetes Insti-
tute, Melbourne, VIC, Australia, and Dr. K.
George M. M. Alberti, Kings College Hospital, London, England, said surgery would not
be the “universal panacea” for obese patients
with type 2 diabetes and pointed out that the
study duration was only 1 year and that surgery has inherent hazards. [N Engl J Med 2012
Mar 26. Epub ahead of print]
“There is also the problem of ‘remission’
versus ‘cure,’” they said. “Type 2 diabetes is
often progressive, and worsening of glycemic
control over time is likely in many patients.
However, some years of improved glycemia
may well result in less microvascular disease.”
Both the researchers and commenters
called for further studies on the long-term
clinical effects of gastric surgery. 4
May 2012
Electronic skin patches for
health monitoring
Radha Chitale
U
ltra thin ‘electronic skin’ patches that
wirelessly relay health information
could free patients who need to be monitored
from inpatient care.
“The technology can be used to monitor
brain, heart or muscle activity in a completely
noninvasive way, while a patient is at home,”
said Dr. John Rogers, a professor of materials
science and chemistry at the University of Illinois at Urbana-Champaign, who developed
the device. “These new materials for electronics can intimately integrate with the human
body.”
The electrical components of the patches
are designed to withstand water, sweat and
movement. Rogers and colleagues accomplished this by preparing the same silicone
used in rigid electronic wafers, in thin membranes cut into a web-like mesh and integrated with silicone rubbers that are laminated to
the skin like a temporary tattoo.
The findings were presented during the
annual meeting of the American Chemical
Society, held recently in San Diego, California, US.
The patch’s sensor functions allow it
to measure a variety of electronic metrics
including, muscle contractions, heartbeat,
brain functions, temperature and hydration.
“Hydration looks like a very interesting
[application] for us,” Rogers said. Measuring
skin hydration has applications in cosmetics
and athletics but Rogers pointed out that certain heart conditions can be spotted based on
the body’s fluid retention.
The device should also be particularly useful for patients who require monitoring by
electroencephalograms, electrocardiograms
and electromyograms.
But the patch could be used for more than
skin surface applications. Rogers said they
could be integrated with advanced surgical
devices to feedback information, on the surface of balloon catheters, for example, to add
a diagnostic function.
In addition to sensory reception, the patch
can also provide electrical stimuli, Rogers
said, which may be useful for physical rehabilitation.
The ‘electronic skin’ patch can stay on the
skin for about 1 week, but beyond 2 weeks
the surface layer of skin cells is naturally
sloughed off.
Rogers said they would need to think about
accommodating this exfoliation process in
situations of long-term monitoring.
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May 2012
Forum
Biobanks: Research dream or
ethical nightmare?
Professor Alastair V. Campbell, Director of the Centre for Biomedical Ethics at the National
University of Singapore, discussed the research potential of large-scale human health databases during the Asia-Pacific Research Ethics Conference, held recently in Singapore.
B
iobanks, large epidemiological cohorts,
including past and present populations,
that are associated with extensive samples of
DNA and other biological materials, linked
to health data, offer a rich source of information for public health research. Data capture
health episodes affecting participants as they
occur and are often followed up for decades.
However, the possibility of information abuse
or use for commercial gain is high. Creating
and maintaining biobanks raises a number of
major ethical questions that should be dealt
with as we strive to define and defend the biocommons.
Opportunities for research
Biobanks warrant unusual consideration.
The data they contain offer a broad range of
possible research opportunities, mined from
a broad range of future health information
that will be captured. This is large-scale data,
with many participants, making it somewhat
impersonal. In addition, a range of researchers will have access to the data for a very long
time.
The major features that make a biobank
enterprise different from a piece of research
are the need for general consent, appropriate
stewardship, and justified trust.
Therefore, special measures are required
for biobanks, rather than holding them to the
same standards of research protocol as other
data sets.
The UK Biobank is the world’s largest resource of genetic health and lifestyle data. It
includes over 500,000 participants aged 4069 and has the unique advantage of gaining
data from the comprehensive British National
Health Service.
This biobank took about 10 years of lead
time in order to clarify the governance and
ethical framework, in addition to public consultations. People would get a letter inviting
them for an assessment at a clinic. A major
part of the visit was spent explaining what
they were giving consent to.
Participants in the UK Biobank consented
to access to medical records for the remainder
of their lives and after their death, without
feedback on the results of their testing, other
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May 2012
Forum
than minor initial tests for basic things like
blood pressure levels.
Consent for use of participant data is rescindable but not conditional. That is, you
cannot specify what type of research you are
willing to allow your tissues to be used for.
The “big brother” scenario
The nightmare scenario would be that “big
brother” is watching. How can we be sure
such databases won’t be used in ways other
than what the participant signed up for? If, for
example, stored genetic information could be
accessed by court order in a society where authorities increasingly want access to citizens?
In addition, if the commercial dominates, the
whole purpose of the collection is in danger.
This is where ethics in governance comes
in. If the ethics governing body believes the
participant’s trust was abused, they say so,
acting as proxy for the people involved.
The governance of the UK Biobank is independent, and they alone guard the ethics
and governance framework. They advise on
revisions, monitor the UK Biobank and report their findings publicly and provide general advice.
‘‘
Creating and maintaining
biobanks raises a number of
major ethical questions that should
be dealt with as we strive to define
and defend the biocommons
Biobanks can be built “from the ground
up”, as the UK Biobank was, but they can
also be created by linking existing collections
of tissue and registry information.
This kind of data consolidation lends itself
to growing into virtual biobanks. Virtual biobanks are gaining popularity as researchers
push to share and use population information across regions.
The issue of access is important in the face
of pressure to link data sets internationally
but it is complicated because there is no consistency in governance across international
biobanks.
Ethicists could discuss whether it is right
to trust international entities with biobank
data without international consistency.
Security measures are important to have
in place to prevent inappropriate access.
Stewards must address who has access to the
biobank data, to what extent access to other
records is controlled and how easy it is to
hack into the resource.
Safeguards to prevent abuse
One solution could be for a virtual biobanks to link registries with safeguards to
prevent identification. A person would be assigned a serial number and the serial number
is linked to the health data as a way to store
data without compromising the safety of the
subject. The link would be stored with an independent trusted third party and without
their cooperation, no one can link the health
information back to the original subject.
Whatever the problems with broad consent,
presumed consent is not sufficient. Biobanks
are more than just a collection of tissue or data.
Researchers have to see these as public property for the common good, uninfluenced by
commercial or nationalist interests. The prospect for large-scale data sharing – for health
not profit – could lead to greater information
and more justice in healthcare. 7
May 2012
Indonesia Focus
Local events calendar
The 3rd Asia Oceanian Conference
of Physical and Rehabilitation
Medicine
Bali, 21-24 Mei 2012
Hotel Discovery Kartika Plaza, Bali
Sekr : Jl. Cakalang Raya No. 28 A, Rawamangun, Jakarta Timur
Tel / Fax : 021-47866390
Email : aocprm2012bali@
pharma-pro.com
Website : www.aocprm2012.org
Perhimpunan Respirologi
Indonesia (Pertemuan Ilmiah
Respirasi 3 Makassar)
Makassar, 25-27 Mei 2012
Hotel Grand Clarion Makassar
Sekr : Division of
Respirology and Clinical Respiratory Disease, Department of internal medicine, Department of pulmonology & respirastory medicine, Faculty of medicine,
University of Hasanudin, 2nd Fl, Infection Center Bldg, RS dr. Wahidin Sudirohusodo, Jl. Perintis Kemerdekaan km.11, Tamalanrea, Makassar 902145
Tel / Fax : 0411-582002
Email : konasperpari
[email protected]
KONAS PDPI XIII
Surabaya, 4-7 Juli 2012
Shangri-la Surabaya
Sekr : Bagian / SMF Ilmu Penyakit Paru, RSUD Dr. Soetomo Surabaya Jl. Mayjen Prof. Dr. Moestopo No. 6-8 Surabaya 60286
Telp/Fax : 031 - 5036047
Email
: konaspdpixiii
[email protected]
Website : http://www.
konaspdpi2012.com
The 9th Congress Of Indonesian
Society of Endocrinology
Manado, 5–7 Juli 2012
Hotel Grand Kawanua
Convention Centre, Manado
Sekr : Bagian Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Indonesia/ RSUP Nasional Dr. Cipto Mangunkusumo
Jalan Salemba 6, Jakarta 10430
Telp : 021-3100075, 3907703
Fax : 021-3928658, 3928659
Email
: [email protected]
Website : www.perkeni.net
7th Symposium on
Nutri Indonesia in
conjunction with 1st
International Symposium
on Nutrition
(From Evidence to Practice)
Jakarta, 5-8 Juli 2012
Hotel Acacia, Jakarta
Sekr : Pacto Convex Ltd
Lagoon Tower, Level B1, The Sultan Hotel
Jl. Jend. Gatot Subroto, Jakarta 10270
Tel : 021-5705800
Fax : 021-5705798
Email : secretariat@
nutriindonesia.org
Website : www.nutriindonesia.org
PIN X PB PAPDI
(Emergency in Internal Medicine)
Balikpapan, 29 Juni–1 Juli 2012
Hotel Gran Senyiur, Balikpapan
Sekr : Gedung ICB Bumiputera, Ground Floor 2B, Jl. Probolinggo No.18 , Gondangdia, Menteng, Jakarta 10350
Tel : 021-2300818
Fax : 021-2300755/2300588
Email : pin9pbpapdi@gmail.
com ; pin9pbpapdi@
yahoo.co.id; pb_papdi@
indo.net.id
KOGI 2012
(Congress Obstetry & Gynecology)
30 Juni – 4 Juli 2012, Bali
Nusa Dua Convention Centre
Sekr : Pogi Jakarta
Tel : 021-3143684
Fax : 021-3910135
Email : [email protected]
54th Anniversary
PAPDI JAYA Preset: Jakarta
Internal Medicine in Daily Practice
31 Agustus – 2 September 2012,
Jakarta
Hotel Borobudur, Jakarta
Sekr : Gedung ICB Bumiputera Lt.1, Jl. Probolinggo 18, Gondangdia, Menteng, Jakarta 10350
Tel : 021-2301267
Fax : 021-2301267
Email : [email protected], [email protected]
The 14th International Meeting
on Respiratory Care Insonesia
(Respina) 2012
5 - 6 Oktober 2012, Jakarta
Hotel Shangri-la, Jakarta
Sekr : Gedung Asma Lt.2, Jl. Persahabatan Raya No.1, Jakarta 13230
Tel : 021-47864646, 47864321
Fax : 021-47866543
Email : info.respina@yahoo.
com, info.respina.
[email protected]
Website : www.respina.org
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May 2012
Indonesia Focus
Bahaya konsumsi gula tambahan berlebih
Hardini Arivianti
M
enurut WHO, masalah obesitas sudah mendunia dan akan bertambah
bila tidak ada upaya untuk mengatasinya.
Diperkirakan tahun 2015, lebih dari sepertiga
penduduk dunia (2,3 miliar) akan mengalami
obesitas. Riskesdas (2007 dan 2010), kejadian
obesitas di Indonesia pada anak balita selama
3 tahun terakhir meningkat, dari 12,2% menjadi 14%.
Tahun 2020 diperkirakan berbagai penyakit akibat pola diet yang salah tersebut, akan
menyebabkan hampir ¾ dari semua kematian
di dunia, yaitu jantung iskemik (71%), stroke
(75%), diabetes (70%) di negara berkembang.
Yang perlu menjadi perhatian adalah secara
global sekitar 60% penyakit-penyakit tersebut akan terjadi di negara berkembang yang
nantinya akan meningkatkan beban anggaran kesehatan bagi pemerintah. Itu sebabnya
WHO merekomendasikan agar konsumsi
gula tambahan tidak melebihi 10% dari total
energi (dibatasi sebanyak 5-8 sendok teh per
hari) terutama pada anak-anak
Gula tambahan
Gula tambahan merupakan gula, baik jenis
alami (fruktosa) maupun buatan (sirop gula
jagung), yang ditambahkan ke dalam proses
pembuatan makanan atau minuman. Proses
tersebut biasa dilakukan guna menguatkan rasa.
Pada Maret lalu, IDI meluncurkan kampanye
“Bahaya Gula Tambahan” untuk mengantisipasi tingginya konsumsi gula (terutama pada
anak-anak) dan berpotensi menyebabkan
ledakan obesitas dan diabetes melitus dini.
Kampanye ini menghadirkan beberapa pem-
bicara yaitu Prof. Dr. dr. Razak Thaha, MSc,
Prof Dr Sidartawan Sugondho SpPD-KEMD,
dan dr. Aman B Pulungan, SpA(K). Sebagai
moderator adalah dr Slamet Budiarto, SH,
MHKes (Sekjen PB IDI)
Menurut Prof.Razak, Indonesia saat ini
tengah mengalami transisi epidemiologi gizi.
Indonesia mulai memasuki pola epidemiologi
gizi ke-4 yaitu berkembangnya penyakit tidak
menular (Non-communicable Disease/NCD),
yang penyebabnya antara lain meningkatnya
asupan lemak, gula, dan makanan olahan.
Biasanya dalam rangka catch up berat badan,
maka pada anak kurang gizi dilakukan pemberian makanan tambahan yang terlalu cepat.
Akibatnya, saat dewasa akan berisiko menderita penyakit kronik.
Penambahan berat badan yang cepat pada anak
kurang gizi akan meningkatkan risiko penyakit
kronis saat dewasa. Anak-anak dengan pertumbuhan awal terganggu kemudian diintervensi sehingga mencapai penambahan berat badan dengan
cepat cenderung memiliki penyakit tekanan darah
tinggi, diabetes, penyakit kardiovaskular dan sindrom metabolik.
Gula merupakan ’makanan’ kedua terbanyak yang dikonsumsi (65,2%) setelah perasa
makanan (77,8%). Konsumsi lemak justru
tidak terlalu banyak, hanya 12,8%. “Hal ini
menunjukkan masyarakat tidak tahu risiko
mengonsumi gula secara berlebihan,” lanjut
pakar gizi klinik dari Ujung Pandang ini.
Kematian penduduk Indonesia menurut
kelompok umur masih dikuasai penyakit
tidak menular. Sesuai data Riskesdas 2007
menunjukkan kematian akibat penyakit tidak
menular mencapai 59,5%, lebih dari penyakit
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May 2012
Indonesia Focus
menular (28,1%). Stroke, hipertensi, diabetes,
tumor dan penyakit jantung adalah lima teratas penyakit tidak menular yang menyebabkan kematian.
Presentasi kematian di Indonesia akibat
penyakit tidak menular pada penduduk < 60
tahun pada 2008, yang ternyata lebih tinggi
daripada angka global. Diabetes misalnya, secara global 23% sementara di Indonesia 25%.
Sedangkan penyakit jantung 18% (global) dan
23% di Indonesia.
Uniknya, pergeseran pola diet tidak
sehat ini justru semakin mengarah ke negaranegara dengan pendapatan rendah, seperti Indonesia. Beberapa ciri yang ditemukan adalah meningkatnya konsumsi
minuman/jajanankayakalori/gulaterutamapada
negara dengan pendapatan rendah, peningkatan asupan makanan olahan padat energi/
gula, penurunan asupan buah, sayur dan
kacang-kacangan serta makin singkatnya
waktu proses makanan dan meningkatnya
penggunaan makanan setengah matang dan
siap saji yang padat energi/gula. Belum lagi
teknologi pengolahan makanan yang makin
maju, mengolah air menjadi minuman kaya
kalori/gula (Gambar 1).
Pada acara Summit Meeting September
lalu, isu paling penting adalah kegagalan
negara berkembang dalam menangani
gizi. Ada 2 jenis program yaitu specific nutrition program (mencakup pola/perilaku
makan) dan sensitive nutrition program.
“Kita mengajarkan anak agar makan sehat namun dimana-mana ada izin begitu
banyak waralaba akibat kebijakan perdagangan sehingga makanan padat energi
sangat murah,” jelas Prof Thaha.
Mengenai anak, sebenarnya yang perlu diperbaiki adalah 9 bulan pertama kehidupan.
Kekurangan gizi saat hamil dapat memper-
buruk masa ‘programming’ yang salah. Saat
anak lahir dengan ‘programming’ yang salah
dengan kekurangan gizi maka akan menimbulkan masalah seperti yang dihadapi Indonesia kini.
Strategi global yang perlu dilakukan
adalah 1000 hari pertama kehidupan anak.
Dengan fokus pada kelompok ‘window of
opportunity’ (calon ibu, ibu hamil, bayi dan
baduta). Bagi calon ibu dan ibu hamil, perlu mengonsumsi makanan beraneka ragam
semua kelompok makanan, menjaga berat
badan ideal, mengupayakan pencapaian BB
ideal mempertahankan pertambahan BB sesuai usia kehamilan dengan menambah porsi
makanan sumber karbohidrat, protein, dan
vitamin, mineral.
Ulah gula lainnya
“Gula yang harus dihindari adalah gula
tambahan,” jelas Prof Sidartawan. Gula
merupakan salah satu sumber karbohidrat
yang diperlukan untuk proses metabolisme
dan termasuk ke dalam refined carbohydrate,
bisa berupa glukosa dan fruktosa. Kedua
jenis gula ini dimetabolisme di hati dengan
cara berbeda. Glukosa masuk ke hati dan
disimpan dalam bentuk glikogen. Sedangkan
fruktosa dimetabolisme dan diekstraksi dari
hati hampir dalam bentuk seutuhnya dan bila
berlebihan dengan cepat akan diubah menjadi glukosa, glikogen, asam laktat maupun
lemak sehingga bisa menimbulkan perlemakan hati. Fruktosa membentuk ‘advanced
glycation end products’ (AGE) 7 kali lebih
banyak dan terbukti secara ilmiah fruktosa
bisa memicu proses toksisitas liver dan menjadi sumber berbagai penyakit kronis.
Fruktosa merupakan gula sederhana yang
didapat dari buah, madu, gula pasir (table
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May 2012
Indonesia Focus
sugar). Fruktosa dalam bentuk high-fructose
corn syrup (HFCS) banyak ditemukan di soft
drink dan minuman energi. Fruktosa akan
disalurkan ke sistem saraf pusat (SSP), hati,
usus, dan jaringan adiposa yang menyebabkan konsekuensi klinis yang berbeda.
Dulu, soft drink dibuat dengan menggunakan
glukosa/sukrosa namun sukrosa harganya mahal. Kini banyak pabrik mencari alternatif gula
dengan mencari yang lebih murah dan lebih
manis, yaitu HFCS. Pada HCFS ini mengandung 55% fruktosa. Dalam penelitian menunjukkan, kalori dari glukosa/sukrosa dibandingkan dengan fruktosa sama namun akibatnya
berbeda. Fruktosa menyebabkan perlemakan
hati, meningkatnya trigliserida, dll. Fruktosa
banyak terkandung di dalam soft drink.
Ulah gula yang lain lagi antara lain, mengurangi supresi hormon ghrelin (merupakan
sinyal lapar untuk otak) dan mengintervensi
transportasi dan sinyal hormon leptin (berfungsi membantu membentuk rasa lapar.
Selain itu, sinyal dopamin di pusat otak pun
berkurang karena gula menimbulkan rasa
nikmat saat berkurangnya konsumsi makanan sehingga orang cenderung untuk mengonsumi makanan lebih banyak lagi.
Malik Vs dkk (Diabetes Care, November 2010) melakukan meta analisis tentang
perilaku mengonsumsi minuman mengandung gula tambahan (sugar-sweetened beverages/SSB) yang dikaitkan dengan risiko sindrom metabolik dan DM tipe 2. Kesimpulan
studi ini, selain meningkatkan berat badan,
konsumsi SSB berlebihan dikaitkan dengan
sindrom metabolik dan DM tipe 2. Data ini
memberikan bukti empiris yang menunjukkan konsumsi SSB harus dibatasi untuk
menurunkan risiko sindrom metabolik kronis
yang terkait dengan obesitas.
Dhingra dkk (Circulation, 2007) mengeluarkan hasil studi komunitas pada dewasa,
konsumsi soft drink berkaitan dengan risiko
tinggi terjadinya sindrom metabolik. 11
May 2012
Indonesia Focus
21st Annual Scientific Meeting of Indonesian Heart Association, Jakarta, April 6-8 2012
Penyakit kardiovaskular pada perempuan
Hardini Arivianti
M
enurut data statistik AHA terbaru, 1
dari 3 perempuan memiliki bentuk
tertentu penyakit kardiovaskular, seperti jantung koroner, stroke, gagal jantung atau hipertensi. Dalam 1 tahun setelah serangan jantung
didapat data, 38% perempuan (dibandingkan dengan 25% pria) akan meninggal dan
setelah 6 tahun, perempuan berisiko 2x lebih
besar dibandingkan pria, akan mengalami
serangan ulang dan menjadi cacat.
Menurut survei besar pada wanita di
Amerika Serikat, 61% teridentifikasi menderita kanker payudara (penyakit yang mereka takuti) padahal hanya 4% yang meninggal dunia akibat kanker tersebut. Yang peduli
dengan penyakit jantung hanya sekitar 8%.
Sedangkan wanita perokok memiliki risiko
2-6 kali mengalami serangan jantung. Hal ini
menjadi salah satu topik pada ‘Annual Scientific Meeting of Indonesian Heart Association’
(ASMIHA) pada awal April lalu dengan tema
“Advances in the Management of Cardiovascular Diseases: the Controversies Continues”.
Presentasi klinis pada wanita juga atipikal,
yang berupa jarang mengalami nyeri pada
retrosternum; nyeri dada yang timbul saat
istirahat, pada malam hari dan stres; rasa
tidak nyaman pada rahang, epigastrium, lengan, bahu dan punggung; dispnea, palpitasi,
pra-sinkop; fatigue, diaforesis, mual.
Guideline update 2011
Salah satu sesi dipresentasikan oleh dr.
Dyah Siswanti Estiningsih, SpJP, dengan
judul “Cardiovascular Disease in Women:
2011 Guideline Update”. Klasifikasi risiko penyakit kardiovaskular (cardiovascular disease/
CVD) pada wanita sesuai dengan guideline
2011 adalah risiko tinggi, berisiko dan kardiovaskular yang ideal. Kriteria risiko tinggi
meliputi manifestasi klinis CHD, CVD, PAD,
DM, aneurisma aorta abdominalis, CKD dan
memiliki risiko prediksi CVD dalam 10 tahun
mendatang sebesar ≥ 10%.
Sindroma metabolik pada perempuan
memiliki 3 dari beberapa kriteria berikut: obesitas abdomen (lingkar pinggang ≥ 35 inci),
kadar trigliserida ≥ 150 mg/dL, kadar HDL
< 50mg/dL, tekanan darah ≥ 130/85 mmHg,
dan kadar glukosa puasa ≥ 100mg/dL.
Dari data obstetrik ginekologi, didapat bila
seorang perempuan pernah mengalami diabetes gestasional, preeklamsia dan sindrom
polikistik ovarium, relative risk (RR) mengalami CVD sesudahnya akan lebih tinggi. Begitu
pula dengan kebiasaan merokok. Perbandingan kejadian koroner antara perokok dan
non-perokok, yang tidak pernah merokok
memiliki RR 1, perokok 1-4 rokok/hari memiliki RR sebesar 3,12 kali dan RR akan meningkat sebesar 5,48 kali bila merokok hingga 15
rokok/hari.
“Sebagai dokter kita harus memberi
semangat pada pasien perempuan perokok
untuk menghentikan kebiasaan ini. Namun
mereka kadang tidak mau berhenti karena
takut berat badannya naik atau akan depresi,” tukas dr. Dyah. Untuk itu, kadang dokter
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Indonesia Focus
perlu meminta mereka berhenti merokok saat
hamil dan tetap tidak merokok setelah masa
itu.
Walau FDA sudah menyetujui beberapa
terapi farmakologi untuk berhenti merokok,
namun sesuai ACOG hingga kini belum ada
terapi farmakologis yang telah disetujui FDA
untuk menghentikan kebiasaan merokok
pada wanita hamil. “Oleh sebab itu, kami
menganjurkan untuk berhenti merokok secara alami.”
Selanjutnya dr. Dyah menjelaskan RR yang
membandingkan berat badan dengan mortalitas yang diakibatkan oleh chronic heart
disease/CHD. Bila indeks massa tubuh (Body
mass index/BMI) dalam nilai normal (< 24,9),
RR mortalitas akibat CHD, sangat rendah.
Namun bila BMI tersebut mencapai hingga
32, maka RR akan meningkat sekitar 6 kali
lipat dibandingkan dengan perempuan yang
memiliki BMI normal.
Keterkaitan antara kenaikan berat badan
– yang dihitung sejak usia 18 tahun – dan
RR, dr. Dyah menukaskan, kenaikan berat
badan sebesar 10-19 kg, maka RR mortalitas
akibat CHD sebesar 3 kali lipat. Bila kenaikan berat badan ≥ 20 kg, maka RR menjadi
7,4 kali lipat.
Ada hal yang baru dalam guideline ini,
yaitu stres psikososial pada perempuan.
Sesuai data dari ’Stockholm Female Coronary Risk Study’, wanita yang mengalami
marital stress berisiko 3 kali lipat mengalami
rekuren CHD. Sedangkan pada wanita yang
tinggal sendiri dan menjadi wanita karir, kondisi ini tidak meningkatkan risiko kejadian
CHD rekuren secara signifikan.
Kadar HDL yang rendah pada perempuan
jauh lebih penting dibandingkan pada pria.
Karena setiap kenaikan 1mg/dL pada kadar
HDL akan menurunkan risiko CHD sebesar
3% dan 2% pada pria. Kenaikan kadar trigliserida pada perempuan dikaitkan dengan
proses aterogenik dibandingkan pada pria.
”Itu sebabnya dokter harus menganjurkan
pasien perempuan untuk melakukan aktivitas fisik yang cukup agar dapat menjaga kadar
HDL yang normal,” jelas dr. Dyah lebih lanjut.
Dokter perlu menganjurkan perubahan gaya
hidup dahulu sebelum memutuskan untuk
memberikan terapi medis. Penurunan kadar
LDL < 70 mg/dL pada wanita yang berisiko
tinggi CHD (atau yang memiliki faktor risiko
CHD tidak terkontrol) mungkin memerlukan
terapi kombinasi penurun kadar LDL.
Pada guideline 2011, tindakan preventif CVD pada perempuan adalah tindakan
intervensi pada gaya hidup yang mencakup
merokok, aktivitas fisik, rehabilitasi kardio,
diet, konsumsi asam lemak omega-3 dan
intervensi faktor risiko (tekanan darah, kadar
lipid, lipoprotein, DM, serta intervensi obatobatan seperti aspirin, beta blocker, ACE
inhibitor dll.
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May 2012
Indonesia Focus
Peran laparoskopi dalam bedah anak
Arlina Pramudianto
T
eknik bedah laparoskopi telah cukup lama
dikenal dalam area bedah umum, yang
a-plikasinya memberikan manfaat dan pemulihan yang lebih cepat dibandingkan teknik bedah
umum konvensional. Bagaimana dengan aplikasinya dalam bedah anak? Laparoskopi pada
pasien dewasa tidak sama dengan laparoskopi
bedah anak, selain ukuran organ pada anak lebih
kecil, diperlukan keahlian dan modalitas yang berbeda walau diterapkan pada kasus yang sama.
Salah satu pioner bedah anak yang piawai
dalam bedah invasif minimal dan bedah urologi
pediatrik adalah Prof. Tan Hock Lim, MBBS, MD,
FRACS, FRCS. Beliau adalah dokter bedah anak
pertama di Universitas Adelaide yang memprakarsai program bedah invasif minimal di rumah
sakit Great Ormond Street Hospital, London.
Selain itu, Prof Tan adalah ahli bedah anak pertama
yang menerapkan laparoscopic pyloromyotomy pada
kasus-kasus stenosis adesiolisis, eksisi laparoskopi
kista koledokus dan menggunakan laparaskopi
diagnostik pada kasus Necrotising Enterocolitis
(NEC). Beliau juga dokter pertama yang melakukan percutaneous nephrolithotomy (PCNL) pada anak
di Melbourne.
Profesor Tan berpendapat bahwa dengan mengubah teknik sayatan besar dalam bedah konvensional yang mengakibatkan disabilitas, disfungsi
dan disfigurement (kecacatan/parut) pada pasien,
maka dengan sayatan kecil dalam teknik laparoskopi, akan mempercepat pemulihan pasien, meminimalisir komplikasi dan tidak meninggalkan
parut yang besar.
Dalam kesempatan nasional dengan lima senter
pendidikan bedah Fakultas Kedokteran di Universitas Syiah Kuala (Aceh), Universitas Gadjah Mada
(Yogyakarta), Universitas Airlangga (Surabaya)
dan Universitas Padjadjaran (Bandung), dan Universitas Indonesia lalu, Prof Tan menyampaikan
kuliah singkat bertajuk ‘The Past, Present and Future of Laparoscopy Surgery’. Beliau mengutarakan asal usul dan perkembangan laparoskopi
pada bedah anak, yang semula digunakan untuk
‘memotong’ organ seperti pada laparoskopi splenektomi, dengan perbaikan teknologi dan instrumen selanjutnya berkembang menjadi tindakan
laparoskopi konstruktif.
Tindakan laparoskopi konstruktif anak yang
pertama dilakukan adalah laparoscopic fundoplication yang selanjutnya menjadi standard emas untuk tindakan fundoplication. Beberapa kasus lain
yang dapat dilakukan bedah laparoskopi pada
anak adalah choledochal cyst, esophageal atresia repair,
microlaparoscopy, dan sebagainya.
Karena kontribusi dan dedikasi Prof Tan
sebagai konsultan laparoskopi bedah anak
dan bersedia membagikan ilmu dan pengetahuannya di FKUI-Indonesia, maka FKUI menganugerahkan gelar ‘Adjunct Professor ‘beberapa waktu yang lalu.
Seremonial gelar ini dilakukan bersamaan dengan penyerahan bantuan enam alat endolaparoscopy dari perusahaan Jerman kepada Departemen Ilmu Bedah Divisi Bedah Anak FKUI-RSCM
oleh Karl Christian Storz, pemilik perusahaan Karl
Storz Endocopy yang dapat diyakinkan oleh Prof
Tan akan potensi perkembangan bedah laparoskopi di Indonesia.
Saat ini, terdapat ahli bedah anak FKUI yang
telah dilatih oleh Prof Tan, yaitu dr. Iskandar
Rahardjo Budianto, SpB.,SpBA dan dr. Riana Pauline Tamba, SpB., Sp.BA yang selanjutnya akan
bekerja dalam tim bedah anak untuk kemajuan
teknik laparoskopi di Indonesia. 14
May 2012
Indonesia Focus
Peran penambahan isomaltulosa bagi anak
Hardini Arivianti
U
ntuk menjaga fungsi otak, kadar glukosa
dalam darah harus selalu terpenuhi. Hal
ini penting pada anak-anak mengingat aktivitas belajar dan banyaknya kegiatan yang
dijalani di sekolah. Di sinilah salah satu fungsi penting sarapan, yaitu memberikan asupan
karbohidrat atau glukosa untuk beraktivitas
dan belajar hingga siang hari.
“Sarapan penting untuk memperbaiki
kemampuan memperhatikan, memahami,
memecahkan masalah, dan menjaga daya
ingat. Nutrisi juga memiliki efek jangka
pendek dan jangka panjang terhadap kinerja
otak,” jelas Dr. dr. Saptawati Bardosono, MSc,
sebagai salah satu peneliti Tim Unit Riset
Kedokteran FKUI yang melakukan penelitian
berjudul “Efek Susu yang Diperkaya dengan Lactose-Isomaltulose terhadap Performa
Kognitif Anak Indonesia: Studi Cross-Over”.
Pakar lain yang termasuk ke dalam tim ini
adalah spesialis anak, Dr. dr. Rini Sekartini,
SpA(K) dan spesialis jiwa anak, Dr. dr. Tjhin
Wiguna, SpKJ (K). Penelitian ini merupakan
hasil kerjasama antara FrieslandCampina (induk perusahaan Frisian Flag Indonesia) dan
Unit Riset Kedokteran Fakultas Kedokteran
Universitas Indonesia. Hasil studi ini telah
dipaparkan beberapa waktu lalu, dan dr.
Dwiputro Widodo, SpA(K) bertindak sebagai
moderator.
Mengenal isomaltulosa
”Sebuah hipotesa menyatakan, kadar glukosa darah sangat penting untuk menjaga
fungsi otak dan banyak studi telah dilakukan
untuk meneliti hal tersebut. Bila kadar glukosa tetap terjaga secara stabil untuk jangka
Anton Susanto, Victoria Valentina, Anne Schaafsma, Saptawati
Bardosono, Tjhin Wiguna, Dwiputro Widodo
waktu yang lama, maka diharapkan fungsi
atensi pun dapat bertahan lebih lama,” jelas
Anne Schaafsma, PhD.
Isomaltulosa termasuk ke dalam golongan karbohidrat yang secara alami terdapat pada madu dan tebu, serta dapat pula
diproduksi dari sukrosa. Bedanya hanya
pada ikatan antar gugus molekulnya, yang
menyebabkan pemecahannya lebih lama,
sehingga memerlukan waktu lebih lama
pula untuk diserap oleh usus. Karena
memerlukan waktu yang lebih lama, maka
glukosa yang masuk ke dalam aliran darah
juga lebih lama, sehingga kadar glukosa darah
tetap terjaga relatif lebih stabil. “Jika sukrosa
normal membutuhkan sekitar 1 jam untuk
dicerna, maka isomaltulosa membutuhkan
waktu lebih dari 3 jam.”
Mengapa hal ini penting? Karbohidrat
seperti maltosa, glukosa, dan maltodekstrin,
akan meningkatkan gula darah dengan cepat
dan memicu respons insulin dengan cepat,
namun kadarnya akan menurun dengan
cepat pula hingga di bawah baseline. Bila hal
ini terjadi pada anak, respon tubuh yang tim-
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May 2012
Indonesia Focus
bul adalah mudah merasa lapar dan timbul
rasa ingin makan.
Salah satu studi pernah dilakukan di
Leeds (Inggris) pada orang dewasa untuk
mengetahui perbedaan indeks glikemik dari
sebuah produk, sebagai efek dari perbedaan
dosis isomaltulosa. Hasilnya menunjukkan
isomaltulosa dosis tinggi dapat menjaga
kadar glukosa darah di atas baseline.
Studi yang sama dilakukan oleh Taib
MNM dkk (2012) di Malaysia dengan desain
studi double-blind, cross-over. Perubahan kadar glukosa darah diperkirakan akan mempengaruhi kinerja kognitif dan perubahan ini
dipengaruhi adanya zat-zat nutrisi tertentu.
Studi ini mengevaluasi efek isomaltulosa
yang dikombinasi dengan laktosa kadar
tinggi terhadap performa kognitif pada anak
usia 5-6 tahun. Tigapuluh anak menerima 4
macam minuman: susu pertumbuhan standar, susu pertumbuhan standar diformulakan, susu pertumbuhan standar dengan
laktosa-isomaltulosa dan minuman glukosa
standar. Kemudian diukur konsentrasi dan
daya ingat anak. Hasil menunjukkan, lebih
rendahnya penurunan tingkat perhatian,
daya ingat dan pengenalan gambar pada yang
diberikan susu dengan isomaltulosa dibandingkan susu biasa. (Hasil studi ini telah dipublikasikan pada jurnal Appetite 2012;
58:81-87).
Studi di Indonesia
Berbagai penelitian tentang isomaltulosa telah dilakukan, salah satunya di Jepang
(Kashimura J dkk, 2003) yang hasilnya
menunjukkan performa mental turun lebih
sedikit dibandingkan dengan yang mengonsumsi sukrosa. Penelitian tahun 2012 (Taib
dkk) di Malaysia, membuktikan lebih sedikitnya penurunan tingkat perhatian, daya
ingat dan pengenalan gambar dengan susu
yang ditambahkan isomaltulosa dibandingkan terhadap susu dengan sukrosa. “Hal
ini perlu dikonfirmasi dengan melakukan
penelitian di Indonesia untuk melihat efek
positif susu pertumbuhan anak terhadap
kemampuan kognitif anak usia 5-6 tahun
terkait daya ingat dan perhatian,” tukas dr.
Saptawati.
Setelah menjalani skrining, dari 100 anak
dari berbagai posyandu di Jakarta (Pusat dan
Timur) hanya 54 anak yang memenuhi kriteria. Semua diharapkan homogen baik status gizi, intelektual, dan kadar hemoglobin.
Jumlah laki-laki dan perempuan sebanding
dan tinggi badan/berat badan sesuai dengan
angka kecukupan gizi anak Indonesia dengan kadar Hb batas normal.
Studi double blind randomized cross-over ini
membandingkan 4 jenis susu yang diberikan persaji 200 cc: A (susu pertumbuhan
standar), B (A + 5 g isomaltulosa), C (A + 2,5 g
isomaltulosa - 0,7 g protein + 0,48 g lemak +
0,22 dietary fiber) dan D (A + 2,5 g isomaltulosa
+ vitamin dan mineral). Masing-masing susu
diberikan selama 2 minggu (14 hari) yang dicross over adalah susu A,B dan C, sedangkan
susu D diberikan bersamaan pada 2 minggu
terakhir.
Pengukuran yang dilakukan pada penelitian ini adalah tingkat perhatian/atensi,
tingkat perhatian berkelanjutan, kecepatan
pemahaman angka, kecepatan dalam memilih, kualitas memori, pengenalan gambar
dan kecepatan ingatan. Kesemuanya ini diukur dengan instrumen khusus menggunakan
program komputer ‘United Bio-source Corporation’ (UBC), ‘Goring-on-Thames’ (UK).
Terlebih dahulu setiap anak dilatih cara
melakukan tes. Setelah semalam puasa dari
jam 9 malam, anak tiba di tempat tes dan
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May 2012
Indonesia Focus
melakukan tes pertama kali sebagai baseline.
Lalu anak diberikan susu dan dites kembali
setiap 60 menit selama 3 jam berikutnya.
Hasil studi dipaparkan oleh dr. Saptawati,
menunjukkan efek lebih baik yang bermakna
terhadap tingkat perhatian, tingkat perhatian berkelanjutan dan kecepatan ingatan
setelah 3 jam pemberian susu. Efek positif
terhadap penurunan perhatian dan daya
ingat didapatkan pada pemberian susu yang
diperkaya dengan isomaltulosa. Memperkaya susu dengan tambahan vitamin dan
mineral tertentu juga menunjukkan efek
positif tambahan pada performa kognitif.
Hasil penelitian ini mirip dengan hasil
penelitian terdahulu. Namun pada penelitian ini lebih spesifik terutama pada susu
yang ditambahkan dengan isomaltulosa
(2,5gr) dengan vitamin dan mineral. Tampak hasilnya lebih baik dibandingkan
dengan susu lain. Isomaltulosa memiliki
indeks glikemik lebih rendah dibandingkan
dengan susu lain, sehingga dapat memberikan energi lebih lama bagi tubuh - termasuk
otak - yang kemudian diharapkan dapat
membantu fungsi kognitif.
“Sebagai pakar gizi, saya melihat susu
adalah sebagai salah satu bahan makanan
yang kaya protein dan kalsium. Studi juga
membuktikan dengan tambahan isomaltulosa dapat membantu mempertahankan atensi
dan daya ingat pada anak, tentu hal ini
sangat bagus dan bermanfaat sekali. Dengan kadar glukosa darah yang dapat dipertahankan, maka diharapkan anak akan tetap
konsentrasi saat di sekolah karena tidak
cepat merasa lapar hingga 3 jam,” jelas dr.
Saptawati. Hasil studi ini juga bermanfaat
pada anak terutama sebagai sumber daya
manusia di generasi yang akan datang.
Mengenai penelitian di Indonesia ini,
Anne Schaafsma, PhD juga menambahkan,
hasil penelitian ini merupakan langkah yang
sangat baik bagi perusahan kami di Belanda
dan Indonesia, karena dari segi pandang
pakar ilmiah, studi ini membuktikan hipotesa yang ada. Selain itu, hasil studi ini ke
depan diharapkan akan bermanfaat untuk
membantu performa anak-anak.
Sebagai peneliti utama studi ini, Dr.dr
Rini Sekartini, SpA(K) menjelaskan penelitian di Indonesia ini menunjukkan
hasil yang signifikan, setelah mengonsumsi
susu pertumbuhan yang mengandung isomaltulosa, parameter kinerja kognitif anak
pada 3 jam setelah konsumsi, relatif stabil.
“Susu dengan isomaltulosa yang diperkaya dengan vitamin dan mineral spesifik,
kemungkinan besar memiliki efek positif
terhadap kerja kognitif pada anak,” tukas
dr. Rini saat peluncuran inovasi susu pertumbuhan anak dengan isomaltulosa sekitar pertengahan April lalu.
Orangtua perlu memahami bahwa otak
memerlukan tingkat asupan energi yang berbeda dengan tubuh. Otak akan tetap aktif
walau anak sedang istirahat. Berat otak pada
anak kurang dari 10% dari total berat tubuhnya, namun otak mengonsumsi 40% dari total energi tubuh yang dibutuhkan. Untuk itu
anak perlu mendapatkan asupan energi yang
konsisten dan lebih tahan lama agar dapat
mendukung kinerja otak yang optimal, baik
saat aktif maupun beristirahat.
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May 2012
Indonesia Focus
Novell Research Grant, bentuk apresiasi
terhadap penelitian di Indonesia
Hardini Arivianti
N
ovell Pharmaceutical Laboratories – sebagai bentuk ‘Corporate Social Responsibility’ (CSR) – menyediakan dana riset ‘Novell
Research Grant’(NRG) sebesar Rp 200 juta (untuk 2 orang pemenang) yang akan diberikan
kepada kalangan medis untuk melakukan riset
penelitian di Indonesia. Hal ini sesuai dengan
visi dan misi yang dimiliki oleh Novell untuk
membantu kemajuan riset di Indonesia. Pada
kegiatan ini Novell bekerjasama dengan Pengurus Besar Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia (PB PAPDI).
Sebenarnya kegiatan penelitian di Indonesia cukup banyak yang dilakukan pada
subyek-subyek dengan lingkup lebih kecil
dan tidak sedikit penelitian tersebut putus
tengah jalan akibat keterbatasan dana. Hal
ini diungkapkan oleh Roy Lembong, selaku
Direktur PT Novell. Novell ‘menggandeng’
PAPDI karena organisasi ini merupakan
sebuah organisasi yang terbiasa dengan
topik-topik ilmiah dan mengetahui riset
penyakit di Indonesia serta berkaitan dengan penelitian penyakit apa yang sangat
dibutuhkan.
“Ini pertama kali Novell bekerjasama dengan PAPDI, yang juga bertujuan untuk memicu kalangan lain untuk melakukan hal yang
sama dalam hal mendukung penelitian medis
di Indonesia, dan bukan hanya farmasi tetapi
juga lembaga-lembaga lain atau perusahaan
non-farmasi guna menjaga kesinambungan
dalam hal riset,” tukas Roy.
“Kami dari PAPDI memberikan acungan
jempol pada farmasi ini karena telah menghibahkan sejumlah dana demi kepentingan
penelitian dan tidak terkait dengan produk-
Pemenang 1: dr. Noor Asyiqah Sofia, MSc, SpPD, dr. Agus Siswanto,
SpPD-KPsi, Prof. dr. AH Asdie, SpPD-KEMD, bersama Roy Lembong
dan tim juri
Pemenang 2: dr. Anna Uyainah, SpPD-KP MARS, bersama Roy Lembong dan tim juri
produk serta kami juga berharap hal ini akan
diikuti oleh farmasi-farmasi atau lembaga
lainnya guna mendukung dokter serta memajukan ilmu terkait,” ungkap Dr. dr. Aru W.
Sudoyo, SpPD-KHOM selaku Ketua PAPDI.
PAPDI berharap penelitian ini bisa menjadi
bahan masukan untuk Kementerian Kesehatan dalam memperkaya usaha kita khususnya
dalam menurunkan morbiditas dan mortalitas dari penyakit dan mendorong dokter
untuk melakukan penelitian.
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May 2012
Indonesia Focus
Kriteria pemilihan
Dua pemenang
Kriteria seleksi proposal riset mencakup:
originalitas (belum pernah dilakukan sebelumnya dan bukan penggandaan riset
sebelumnya di Indonesia dan luar negeri),
fungsionalitas (hasil riset berguna sebagai
tindakan aplikasi medis dan bukan hanya
sekadar hasil riset secara statistik yang tidak
dapat diterapkan secara klinis-medis pada
pasien), morbiditas dan mortalitas (hasil
riset dapat mengurangi angka mobiditas dan
mortalitas), frekuensi kasus, dan probabilitas
aplikasi (kemungkinan suksesnya hasil riset
agar dananya dapat digunakan sebagai pedoman aplikasi medis pada pasien).
Dewan juri terdiri dari Dr. dr. Aru W.
Sudoyo, SpPD-KHOM, Prof. Dr. dr. Idrus
Alwi, SpPD, K-KV, FINASIM, dr. Tjahjadi
Robert Tedjasaputra, SpPD, K-GEH, FINASIM dan dr. Sally A Nasution, SpPD-KKV,
FINASIM. “Kami sepakat mengenai topik
penelitian tidak molekuler, tidak high tech,
dan bukan sesuatu yang merupakan translational research (dari laboratorium ke klinik),
namun melainkan yang sudah teraplikasi,”
jelas dr. Aru.
Pada tanggal 3 April 2012 lalu, NRG pertama ini jatuh pada dr. Noor Asyiqah Sofia, MSc,
SpPD dan tim (FK UGM Yogyakarta) dengan
judul ‘Pengaruh Kombinasi Fluoxetine dan
Latihan Pasrah Diri terhadap Kontrol Gula
Darah, Derajat Inflamasi dan Kualitas Hidup’.
Proposal ini berbeda dengan proposal riset lain
karena dilakukan oleh berbagai ahli dari disiplin ilmu yang berbeda-beda termasuk spiritual,
dengan harapan memberikan hasil optimal
bagi pasien diabetes yang di Indonesia jumlahnya sudah mencapai jutaan orang.
Pemenang berikutnya jatuh pada dr. Anna
Uyainah, SpPD-KP, MARS (FKUI RSCM,
Jakarta), dengan proposal berjudul ‘Faktor
yang Mempengaruhi Eksaserbasi Akut Penyakit Paru Obstruktif Kronik pada Jamaah Haji
Embarkasi Jakarta’ akan sangat berguna bagi
para calon jamaah haji yang berjumlah jutaan
orang setiap tahunnya guna membantu meringankan penderitaan bagi yang memiliki PPOK
selama *ibadah haji. Penyerahan dana dilakukan secara simbolik oleh Ketua Umum PB
PAPDI yang dilanjutkan dengan penandatanganan MoU.
19
May 2012
News
World Sepsis Day to highlight global
emergency
Rajesh Kumar
T
he acute care community has designated 13
September 2012 as World Sepsis Day to highlight a global medical emergency that kills more
than 10,000 people worldwide every day – more
than from prostate cancer, breast cancer and HIV/
AIDS combined.
Sepsis arises when the body’s response to an
infection injures its own tissues and organs. If not
recognized and treated promptly, it can lead to
shock, multiple organ failure or death. With hospital mortality rates of 30 to 60 percent, sepsis
remains the primary cause of death from infection in both the developed and developing world
despite advances in modern medicine, including
vaccines, antibiotics, and acute care.
According to the Global Sepsis Alliance (GSA),
which represents about 250,000 intensive and critical care physicians around the world, the prevalence of sepsis has increased dramatically over
the last decade, by 8 to 13 percent annually in the
developed world alone. The GSA attributes this
trend largely due to ageing populations and the
increased use of high-risk interventions, alongside the development of drug resistance and
more virulent varieties of pathogens.
It has also been suggested that the way sepsis
interventions are being delivered is haphazard,
with less than one in five patients receiving appropriate or adequate care according to international guidelines.
“Rapid initiation of simple, timely interventions can halve the risk of dying. Early sepsis treatment is cost effective and reduces hospital and
critical care bed days for patients. Unfortunately,
sepsis is still mostly overlooked and recognized
too late,” said Dr. Ron Daniels, Chairman of the
UK Sepsis Group and executive director of GSA.
Professor Younsuck Koh of the department of
pulmonary and critical care medicine at University of Ulsan College of Medicine in Seoul, Korea,
cited an Asian observational study which showed
the basic principles of giving fluid on time, taking
blood culture samples to detect pathogen, and
administering antibiotics on time were closely related to patient outcomes.
“The three components could be followed
even in resource limiting countries. However, we
found that blood cultures and broad spectrum
antibiotics on time were performed in around
two-thirds of the patients, and the central venous pressure measurement as an index for fluid
resuscitation was performed only around onethird,” said Koh.
The study involved 1,285 adult patients with
severe sepsis admitted in 150 intensive care units
in 16 Asian countries in July 2009. The main outcome measure was compliance with the Surviving Sepsis Campaign’s resuscitation (6 hours)
and management (24 hours) components.
High income countries, university hospitals, intensive care units with an accredited fellowship program and surgical intensive care units were more likely to be
compliant with the resuscitation component.
The situation is not much better in developed
countries. World Sepsis Day aims to change
that through education and active engagement
of physicians, decision makers and the general
public all over the world. 20
May 2012
News
White rice link to diabetes stirs debate
Rajesh Kumar
A
recent meta-analysis linking regular
white rice consumption to significantly
elevated risk of type 2 diabetes has stirred up
some controversy.
The analysis, conducted by researchers
from the Harvard School of Public Health
in Boston, Massachusetts, US, included data
from four primary prospective cohort studies, two of which were conducted in Asia
(China and Japan) and the other two in
the West (USA and Australia). [BMJ 2012;
DOI:10.1136/bmj.e1454]
The results showed that higher white rice
intake is associated with a significantly elevated risk of type 2 diabetes. Assuming a
serving size of white rice of 158 grams, the
researchers estimated that the risk of type 2
diabetes is increased by 10 percent with each
additional serving.
Dr. Daphne Gardner, associate consultant
in the department of endocrinology at Singapore General Hospital, cautioned physicians against a simplistic interpretation of
the study data, saying the methods used to
quantify white rice consumption in the primary studies were very imprecise, which
made the analysis based on their pooled
summary data also imprecise.
“Asian diets are known to rely on white
rice as a staple food, with some studies reporting white rice contributing to nearly
three-quarters of the glycemic load. Should
Western diets contain equivalent amounts of
carbohydrates (glycemic load), but of an alternative form (eg, bread or potatoes), would
the same effect be seen?” asked Gardner.
She suggested that the main question
ought to be: “How much of the diet (ie, proportion of macronutrient) should consist of
carbohydrates and what implications does
this have for the increased risk of type 2 diabetes?”
Dr. Cho Li Wei, consultant in the department of endocrinology at Changi General
Hospital agreed, saying the observational
nature of the study limited the ability to state
cause and effect and controlled studies were
needed to determine if white rice indeed increases the risk of type 2 diabetes.
Gardner said the study had few immediate implications for physicians, patients or
public health authorities.
“It should certainly not support large
scale action to change the dietary habits of
Asian populations which have been present for centuries. In order to determine the
contribution of white rice to developing
type 2 diabetes, one would need a prospective large-scale randomized controlled trial,
with the intervention group having modified
white rice consumption. However, such a trial is unlikely to happen.
“The important take home message is:
more fiber is always beneficial. And this may
take the form of increased consumption of
vegetables or less-processed foods (raw oats
rather than processed cereal). In addition,
portion control of calorie intake (whether this
is protein, carbohydrate or fat) is important in
maintaining a healthy weight and reducing
the overall risk of developing type 2 diabetes,” she said. 21
May 2012
News
C-section raises breathing problem risk
in preemies
Rajesh Kumar
C
esarean delivery may contribute to
breathing problems among pre-term babies, according to new research presented at
the 32nd Annual Society for Maternal-Fetal
Medicine meeting held recently in Dallas,
Texas, US.
In the study, small-for-gestational-age babies delivered by a Cesarean section (C-section) before 34 weeks of pregnancy had a 30
percent increased risk of developing respiratory distress syndrome (RDS) than babies
born vaginally at a similar gestational age.
Researchers from the department of maternal-fetal medicine at the Johns Hopkins and
Yale schools of medicine in the US reviewed
birth certificate and hospital discharge information for 2,560 small-for-gestational-age babies who were delivered preterm.
The increased odds for RDS persisted after
controlling for maternal age, ethnicity, education, pre-pregnancy weight, gestational age at
delivery, diabetes and hypertension. C-section
compared with vaginal delivery was associated with increased odds of 5-minute APGAR
(appearance, pulse, grimace, activity, respiration) score of <7 using unadjusted odds (odds
ratio: 1.4; 95% CI 1.1-1.9), although this difference dissipated after adjusting for confounding factors.
“The findings overturn conventional wisdom that C-sections have few or no risks for
the baby and are consistent with the effort(s)
to end medically unnecessary deliveries before 39 weeks of pregnancy,” said Dr. Diane
Ashton, deputy medical director of the March
of Dimes, an American charity that works
with hospitals and health policy experts to
reduce the number of medically unnecessary
C-sections.
“Although in many instances, a C-section
is medically necessary for the health of the
baby or the mother, this research shows that
in some cases the surgery may not be beneficial for some infants,” said Ashton.
Singapore obstetrician and gynaecologist
Dr. Kelly Loi said the study results are likely to be skewed because it was done retrospectively. Small and premature babies born
through C-section are more likely to have respiratory distress anyway, said Loi.
“Babies who need early delivery are compromised already and the outcome may not
be due to the C- section. For full term babies,
the risk of respiratory distress following Csection falls from 37 weeks to 39 weeks,” she
said.
One million babies worldwide die each
year as a result of their early birth. Babies
who survive an early birth often face the risk
of lifelong health challenges, such as breathing problems, cerebral palsy, learning disabilities and others.
If a pregnancy is healthy and there are no
complications that require an early delivery,
women should wait until labor begins on its
own, or until at least 39 weeks of pregnancy,
since many of the baby’s important organs,
including the brain and lungs, are not completely developed until then, said Ashton.
23
May 2012
News
Breast cancer survivors can learn to
handle hot flushes, night sweats
Radha Chitale
C
ognitive behavioral therapy (CBT) is effective at reducing the hot flushes and
night sweats (HFNS) that are common following treatment for breast cancer, according
to a study.
HFNS, which the study researchers reported affect up to 85 percent of women after
breast cancer treatment, are sources of distress
and negatively impact patient quality of life.
Hormone replacement therapy for HFNS,
used among affected women who are menopausal, is contraindicated or undesirable in
cancer patients. Previous research has shown
reductions in HFNS with paced breathing and
the researchers reported pilot trials showed
promise for CBT.
“The improvement in social functioning
after CBT is relevant because women report
finding hot flushes especially difficult to deal
with at work and in other social situations,”
the researchers said. “Additionally, group
CBT provided sustained benefits to depressed
mood and sleep and some improvements in
dimensions of quality of life. “
Women from breast clinics in the UK who
had at least 10 HFNS episodes per week after breast cancer treatment were randomized to receive usual care (N=49) or usual
care plus one 90-minute session per week
of group CBT (N=47). [Lancet Oncol 2012
Mar;13:309-318]
Usual care included follow-up visits
to oncologists or clinical nurse specialists
every 6 months and as needed, telephone
support from a cancer survivorship program, information leaflets, and advice
about HFNS and treatment options, including symptoms management, paced breathing and relaxation.
The CBT program was based on the causal and maintaining factors of HFNS, including anxiety, stress, embarrassment, negative
beliefs and catastrophic thoughts, and the
resultant behaviors, which can impact patient outcomes, such as avoidance activities.
Women receiving CBT spent 6 weeks in
structured, interactive group classes where
they were given information about the
physiology of HFNS, taught paced breathing, relaxation techniques and behavioral
strategies to manage HFNS.
The weekly plan included discussions on
topics including handling HFNS, the role of
stress, and what cognitive factors might contribute to it. Women were given the opportunity to describe their own experiences with
HFNS as a result of breast cancer, their triggers and outline their treatment goals.
CBT significantly reduced HFNS after 9
weeks and the results were maintained at
24
May 2012
News
26 weeks compared with usual care (adjusted mean difference in HFNS problem
rating [1-10 scale] -1.67 and -1.76, respectively; P<0.0001). Women reported sustained benefits to mood, sleep and quality
of life.
tions are still restricted for these women…
the most cost effective method of delivering
the group CBT would probably be to include it as part of survivorship support program, delivered by trained and supervised
breast-care nurses.” Current treatments for HFNS are nonhormonal drugs such as selective serotonin
reuptake inhibitors (SSRIs) or gabapentin
that result in moderate reductions in HFNS
frequency — about 37 percent across trials,
the researchers reported, but with few improvements in quality of life.
“We do not know whether HFNS were
caused by breast cancer treatments or
whether women were naturally menopausal when they had breast cancer,” the
researchers said. “However, treatment op-
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25
May 2012
News
Bergamot orange a natural
supplement for cholesterol control
Rajesh Kumar
An Australian cardiologist has found a
natural ally in his fight against metabolic disorders – an extract of the bergamot orange,
an Italian citrus fruit which has long been believed to possess heart health benefits.
Dr. Ross Walker, who runs a private practice in Sydney, said he has successfully used
the extract in about 700 of his registered patients who are overweight with dyslipidemia
and elevated blood sugar levels.
Within a few weeks of starting the supplement, some of those patients have totally
avoided the need for statins while others
have reduced their statin dose to control dyslipidemia. As a bonus outcome, their blood
glucose and middle obesity have also significantly reduced, said Walker.
His findings are consistent with those of
an unpublished clinical study conducted in
Italy involving more than 200 patients with
hyperlipidemia. In the study, 1 month’s supplementation with bergamot reduced LDL
cholesterol by 39 percent and blood sugar by
22 percent, and raised HDL cholesterol by 41
percent.
“Bergamot contains extremely large
amounts of polyphenols, as compared to
other citrus species. Two of these, Brutelidin
and Metilidin, directly inhibit cholesterol biosynthesis in a similar way to statins and they
are not found in any other citrus derivatives,”
said lead study author Dr. Vincenzo Mollace,
professor in the faculty of pharmacology at
the University of Cantanzaro in Italy.
Bergamot extract blocks the HMG CoA
reductase enzyme at a different level than
statins. As a result, myalgia and other side effects typically associated with statins can be
avoided because bergamot does not block the
component that depletes the muscular co-enzyme q10, said Walker.
“Bergamot extract (BergametTM) also inhibits cholesterol absorption in the gut, the
same way plant sterols do. That’s why I ask
my patients to take it 15 minutes before meal
twice a day, in the afternoons and evenings,
to block cholesterol absorption from food,”
he said.
“The unique and most important action
of bergamot, due to which cardiologists (like
me) are supporting this, is that it affects metabolic syndrome as a whole: raising HDL cholesterol, lowering LDL and blood sugar and
reducing arterial stiffness and middle obesity.”
Could patients be advised to consume bergamot juice as part of a healthy diet to prevent
metabolic syndrome, rather than taking its
extract in a pill form? Walker said it is not that
easy since bergamot orange is extremely bitter/sour and large amounts of its juice would
be needed to get the desired benefit.
“[Bergamot extract] is not a replacement
for statins. Patients who have had a heart attack or have vascular disease do need to take
statins. [But] the extract can be useful in preventing metabolic syndrome, correcting it in
early stages and as a supplement to reduce
statin dose,” he said.
26
May 2012
News
Omega-3 fatty acids help slow aging of
the brain
Rajesh Kumar
T
he status of omega-3 fatty acids as ‘brain
food’ is well established. However, research now suggests a diet lacking in these
fatty acids may cause brain to age faster and
lose some of its memory and thinking abilities.
The finding has prompted a study author
to recommend that physicians should remind
patients to regularly consume fatty fish or
other food sources of omega-3 as part of a balanced diet.
“[In the study] people with lower blood
levels of omega-3 fatty acids had lower brain
volumes that were equivalent to about 2 years
of structural brain aging,” said lead researcher Dr. Zaldy Tan of the Easton Center for Alzheimer’s disease research and the division
of geriatrics at the University of California at
Los Angeles, California, US.
A total of 1,575 people with an average age
of 67 and free of dementia underwent MRI
brain scans for the study. They were also given tests that measured mental function, body
mass and omega-3 fatty acid (comprising docosahexaenoic acid or DHA, and eicosapentaenoic acid, EPA) levels in their red blood cells.
[Neurology 2012;78: 658-664].
Fatty acid composition of red blood cells
(RBC) reflects dietary fatty acid intake averaged over the RBC lifespan of up to 120 days,
whereas plasma concentrations reflect intake
over only the last few days.
The researchers found that people whose
The regular consumption of fatty fish or other food sources
of omega-3 fatty acids is well known to be part of a balanced
diet.
DHA levels were among the bottom 25 percent
of the participants had lower brain volume
compared to people who had higher DHA
levels. Similarly, participants with levels of all
omega-3 fatty acids in the bottom 25 percent
also scored lower on tests of visual memory
and executive function, such as problem solving and multi-tasking and abstract thinking.
“Lower DHA levels are associated with
smaller brain volumes and a ‘vascular’ pattern of cognitive impairment, even in persons
free of clinical dementia,” concluded the researchers.
It may be premature for physicians to
advise their patients to consume adequate
amounts of food rich in omega-3 specifically
for their brain health, without evidence from
a large randomized control trial. But Tan said
there is already ample evidence supporting
the benefits of this fatty acid in cardiovascular
and overall health and such an advice could
only be beneficial.
27
May 2012
News
Even mild hearing loss increases risk
of falling
Rajesh Kumar
A
dults aged 60 and older should be routinely screened for hearing loss and
treated according to best practice guidelines,
according to Dr. Frank Lin, assistant professor
of otolaryngology at the Johns Hopkins University School of Medicine and Bloomberg
School of Public Health in Baltimore, Maryland, US.
The advice follows research findings that
link even mild hearing loss to a three-fold risk
of falls. Hearing loss among the elderly is already associated with a range of social and
cognitive problems, including dementia. But
the researchers feel the latest finding could
help in the development of new ways to prevent falls and resulting injuries that cost billions of dollars in health care.
“We still do not know if treating hearing
loss can reduce falls. But hearing loss treatment entails no risks and could potentially
only lead to benefits for cognitive, social and
physical functioning,” said Lin, adding that
hearing loss was only one of many potential
risk factors for falls.
To determine whether hearing loss and
falling are connected, Lin and colleagues used
data from the 2001 to 2004 cycles of the US
National Health and Nutrition Examination
Survey. A total of 2,017 participants aged 40
to 69 had their hearing tested and answered
questions about whether they had fallen over
the past year. [Arch Intern Med 2012;172:369371]
They also collected demographic information, including age, sex and race, and tested
participants’ vestibular function, a measure of
how well they kept their balance. They found
that people with a 25-decibel hearing loss, classified as mild, were nearly three times more
likely to have a history of falling. Every additional 10-decibels of hearing loss increased the
chances of falling by 1.4 fold (95% CI, 1.3-1.5).
‘‘
Gait and balance are ...
actually very cognitively
demanding
The finding held true even when researchers accounted for other factors linked with
falling, including age, sex, race, cardiovascular disease and vestibular function. Excluding
participants with moderate to severe hearing
loss from the analysis also didn’t change the
results.
Among the possible explanations for the
link is that people who can’t hear well might
not have good awareness of their overall environment, making tripping and falling more
likely, said Lin.
Another reason hearing loss might increase
the risk of falls is cognitive load, in which the
brain is overwhelmed with demands on its
limited resources.
“Gait and balance are things most
people take for granted, but they are actually
very cognitively demanding. If hearing loss
imposes a cognitive load, there may be fewer
cognitive resources to help with maintaining
balance and gait,” he said.
28
May 2012
Urology
Odor may help signal UTI in children
Elvira Manzano
F
oul-smelling urine may predict urinary
tract infection (UTI) in children with unexplained fever, according to a leading pediatrician.
Dr. Marie Gauthier, from the department of
pediatrics, Sainte-Justine University Hospital
Center, Montreal, in Quebec, Canada, cited
the results of her own study which showed
that malodorous urine was associated with
UTI (odds ratio [OR] 2.83, 95% CI 1.54 to 5.20).
[Pediatrics 2012; DOI:10.1542/peds.2011-2856]
The association persisted despite adjustment for other UTI risk factors such as gender
and the presence of vesicoureteral reflux – abnormal flow of urine from the bladder to the
upper urinary tract (OR 2.73, 95% CI 1.46 to
5.08).
“Parental reporting of malodorous urine
increased the probability of UTI among
young children,” Gauthier said. However, she
cautioned that “the association is not strong
enough to definitely rule in or out a diagnosis
of UTI.”
In this prospective consecutive cohort
study, Gauthier and colleagues surveyed the
parents of 331 children, aged 1 to 3, tested in
the emergency department of a hospital in
Canada for suspected UTI, about their child’s
past medical history and symptoms. Of eight
questions, two were on whether their child’s
urine smelled stronger than normal.
Of the 331 children, 51 met the UTI diagnosis criteria. Bad-smelling urine was the risk
factor most strongly linked to UTI – 57 percent of the children who tested positive for
a UTI had malodorous urine, while only 32
A study conducted in Canada suggests that malodorous urine may
predict UTI in children.
percent of children who tested negative had
pungent urine. Patients with UTI also had a
fever of unknown origin as did 92 percent of
those without.
Gauthier suspects that the foul odor may
be due to the production of ammonia from
bacteria. She said the study findings are more
useful for doctors than parents who, very often, would not ask about urine odor when
a child is assessed in the ER for non-specific
symptoms such as unexplained fever or irritability.
“It should make the clinician more suspicious of this type of infection,” Gauthier concluded.
The bacterium Escherichia coli causes the
vast majority of UTIs in children. Throughout childhood, the risk of having a UTI is 2
percent for boys and 8 percent for girls. Most
cases respond to antibiotics but serious infections may cause kidney scarring or blood
poisoning if left untreated. 29
May 2012
In Practice
Managing acute otitis media:
Strategies for GPs
Dr. Eng Soh Ping
Consultant ENT Surgeon
Ascent Ear Nose Throat Specialist Group
Mount Elizabeth Medical Centre
Singapore
Disease of childhood
Acute otitis media (AOM) – inflammation
of the middle ear – is the second most common disease of childhood after upper respiratory tract infection (URTI). Most children
have at least one or two episodes during
childhood; many have repeated episodes –
with the peak incidence occurring between
ages 2 and 5.
Obstruction of the Eustachian tube is the
most important antecedent event linked to
this condition. Children are particularly susceptible because they have shorter and more
horizontal Eustachian tubes than adults
which are not fully developed and are more
difficult to drain. With age, however, part of
the tube ossifies to bone and the horizontal
angle descends, increasing the downward
flow of fluid.
‘‘
We cannot predict which
patients will go on to develop
complications. Thus, we should
be aggressive, but a little cautious,
when managing AOM
Surgery takes only 10 minutes but recovery takes a few days.
A bulging erythematous
tympanic membrane.
Otitis media with effusion
resolves without surgery.
What causes
AOM?
Otitis media is
caused by viral
and bacterial inA grommet tube in position.
fections. The most
common bacteria responsible are Streptococcus pneumoniae,
Streptococcus pyogenes, Staphylococcus aureus
and Moraxella catarrhalis. Among older children, the most common cause is Haemophilus
influenzae.
30
May 2012
In Practice
The vast majority of AOM episodes are
triggered by URTIs. Eustachian tube dysfunction is a major risk factor. If the Eustachian
tube becomes blocked, fluid can build up and
lead to infection. Other risk factors for acute
ear infections are attending daycare, changes
in altitude or climate, recent ear infection and
genetic factors. The child’s position during
bottle-feeding, for example lying down, also
predisposes the child to AOM. For this reason, breast-feeding position – semi-Fowler’s –
may be good for normal Eustachian function.
Signs and symptoms to watch out for
When the middle ear – which is normally
sterile – becomes acutely infected, pressure
builds up behind the eardrum, resulting in
otalgia. The tissues surrounding the tubes
swell and fluid accumulates in the middle ear.
Pyrexia, with or without co-existing URTI, is
a common symptom in children of any age.
Aside from earache, older children may complain of fullness in the ear and conductive
hearing loss, which is usually transient.
In young children, complaints of ear pain
can be muted and only represented by crying,
irritability and sleeping or feeding difficulties. Severe infections or untreated cases may
cause the eardrum to rupture, causing the pus
to drain from the middle ear to the ear canal.
The condition usually resolves with pharmacological treatment. However, what we
are worried about are those cases that do not
rupture and have become complicated. More
commonly, it would lead to mastoiditis which
requires emergency surgery. Untreated, the
infection can spread to surrounding structures, affecting the brain and the facial nerves.
Diagnosing AOM
The presence of the above symptoms, combined with a complete clinical history and
accurate visualization of the tympanic membrane may lead GPs to the diagnosis of acute
otitis media – one of the three presentations of
otitis media (OM), the other two being recurrent otitis media and otitis media with effusion (OME) or glue ear.
A direct examination of the middle ear
with an otoscope will reveal erythema, bulging and apparent opacity. The normal tympanic membrane moves in response to pressure changes. In AOM, mobility is reduced or
absent with pneumatic otoscopy. An accurate
clinical diagnosis is possible in most cases,
but this is a challenge to physicians as the canal is small and the view may be obscured by
earwax. Crying may also distend the small
blood vessels in the eardrum, mimicking the
redness associated with AOM.
Another useful but lost skill among physicians is the use of tuning fork. If the child is
cooperative, tuning fork tests – both Weber
and Rhine tests – may be performed to distinguish between conductive and sensorineural
hearing loss.
Clinical guidelines for AOM
GPs can refer to the American Academy
of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) guidelines
when diagnosing and treating AOM. In the
EENT circle, we use the American Academy
of Otolaryngology-Head and Neck Surgery
(AAO-HNS) clinical practice guidelines. The
guidelines support the use of antibiotics, but
an initial observation period of 48 to 72 hours
is recommended for select cases to determine
if the infection will resolve on its own.
Current guidelines tend to be less aggressive although some parents may push for
more active treatment due to anxiety and distress from seeing their children suffer.
31
May 2012
In Practice
Treating AOM
Most children with uncomplicated AOM
recover fully without intervention, which is
why some clinicians adopt the wait-and-see
approach. However, we cannot predict which
patients will go on to develop complications.
Thus, we should be aggressive, but a little
cautious, when managing AOM.
AOM is treated just like any URTIs. Amoxicillin is the initial treatment of choice. Analgesics and antipyretics may be used for
symptomatic management. If symptoms do
not resolve after 48 hours and there is abscess, refer. Instrumentation and support
may be limited under primary care setting. It
helps to be on the careful side. Do not underestimate the problem. When in doubt, refer.
‘‘
It takes a sound judgment
and due diligence to be
able to spot early signs of
complications
Otitis media with effusion usually resolves
without surgery. Complex cases that have
not responded to antibiotic therapy however
require tympanocentesis – puncture of the
tympanic membrane – to aspirate fluid or to
facilitate delivery of medication directly to
the middle ear.
In chronic cases with effusions, we do
myringotomy with insertion of tympanostomy tube, called grommet, to allow ventilation and drainage. Surgery often takes less
than 10 minutes although it takes a few days
to fully recover. The tube will also self-extrude in 3 to 6 months.
Take home message for GPs
GPs, being at the heart of the community,
have an important role to play in managing
AOM. A sharp clinical acumen may not be
enough to arrive at a good diagnosis. Paying
attention to detail definitely has an added
value. Rubbing of the ear, for example, may
not mean anything, but it is a significant
symptom in young children with AOM.
Finally, it takes a sound judgment and
due diligence to be able to spot early signs
of complications. The infection can spread
beyond the mucosal structures of the middle
ear resulting in mastoiditis, facial nerve palsy, chronic otitis media, meningitis or brain
abscess. Sagging of the posterior canal wall
and swelling of post auricular areas with loss
of skin crease usually signal danger signs
that should alert clinicians and lead to ENT
referral.
Online Resources:
American Academy of Pediatrics
www.aap.org
American Academy of Otolaryngology,
Head and Neck Surgery
www.entnet.org
Pediatrics
pediatrics.aappublications.org/
content/113/5/1451.long
32
May 2012
Calendar
May
5th European Clinam Conference for
Clinical Nanomedicine
7/5/2012 to 9/5/2012
Location: Basel, Switzerland
Info: Clinam, European Foundation for Clinical
Nanomedicine
Tel: (11) 41 61 695 9395
Fax: (11) 41 61 695 9390
Email: [email protected]
Website: www.clinam.org
19th European Congress on Obesity
9/5/2012 to 12/5/2012
Location: Lyon, France
Info: European Association for the Study of Obesity
Tel: (44) 20 8783 2256
Fax: (44) 20 89796700
Email: [email protected]
Website: www.eco2012.org
American Thoracic Society International
Conference 2012
18/5/2012 to 23/5/2012
Location: San Francisco, California, US
Tel: (1) 212 315 8652
Email: [email protected]
Website: www.thoracic.org/go/international-conference
American Society of Hypertension
19/5/2012 to 22/5/2012
Location: New York, New York, US
Info: American Society of Hypertension
Tel: (1) 212 696 9099
Fax: (1) 212 696 0711
Email: [email protected]
Website: www.ash-us.org/Scientific-Meetings/Future-Meetings.
aspx
Digestive Diseases Week 2012
19/5/2012 to 22/5/2012
Location: San Diego, California, US
Info: American Society of Gastrointestinal Endoscopy
Tel: (1) 301 272 0022
Fax: (1) 301 654 3978
Email: nmurphy@gastro .org
Website: www.ddw.org
19th WONCA Asia Pacific Regional Conference
24/5/2012 to 27/5/2012
Location: Jeju, Korea
Tel: (82) 2 566 6031
Email: [email protected]
Website: www.woncaap2012.org
June
2012 American Society of Clinical Oncology
Annual Meeting
1/6/2012 to 5/6/2012
Location: Chicago, Illinois, US
Tel: (1) 571 483 1300
Email: [email protected]
Website: chicago2012.asco.org
10th Royal College of Obstetricians and
Gynecologists International Scientific Congress
5/6/2012 to 8/6/2012
Location: Kuching, Malaysia
Tel: (60) 3 6201 1858
Email: [email protected]
Website: www.rcog2012.com
15th International Congress of Infectious
Diseases
13/6/2012 to 16/6/2012
Location: Bangkok, Thailand
Tel: (1) 617 277 0551
Fax: (1) 617 278 9113
Email: [email protected]
Website: www.isid.org/icid
15th World Congress of Pain Clinicians
27/6/2012 to 30/6/2012
Location: Granada, Spain
Info: Kenes International
Tel: (41) 22 908 0488
Fax: (41) 22 9069140
Email: [email protected]
Website: www.kenes.com/wspc
33
May 2012
Calendar
Upcoming
17th World Congress on Heart Disease 2012
27/7/2012 to 30/7/2012
Location: Toronto, Ontario, Canada
Info: International Academy of Cardiology
Tel: (1) 310 657 8777
Fax: (1) 310 659 4781
E-Mail: [email protected]
Website: www.cardiologyonline.com
European Society of Cardiology Congress 2012
25/8/2012 to 29/8/2012
Location: Munich, Germany
Info: European Society of Cardiology
Tel: (33) 4 9294 7600
Fax: (33) 4 9294 7601
E-Mail: [email protected]
Website: www.escardio.org/congresses/esc-2012
15th Biennial Meeting of the European Society for
Immunodeficiencies (ESID 2012)
3/10/2012 to 6/10/2012
Location: Florence, Italy
Tel: (41) 22 908 0488
Fax: (41) 22 732 2850
Email: [email protected]
Website: www.kenes.com/esid
42nd Annual Meeting of the International
Continence Society
15/10/2012 to 19/10/2012
Location: Beijing, China
Tel: (41) 22 908 0488
Fax: (41) 22 906 9140
Email: [email protected]
Website: www.kenes.com/ics
World Allergy Organization International
Scientific Conference (WISC 2012)
6/12/2012 to 9/12/2012
Location: Hyderabad, India
Info: World Allergy Organization
Tel: (1) 414 276 1791
Fax: (1) 414 276 3349
E-mail: [email protected]
Website: www.worldallergy.org
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35
May 2012
Humor
“Smile, you’re on Candid Camera!”
“If you think these pills are too
expensive, we will be more than
happy to operate!”
“Sorry folks, I’m running a little behind today!”
“Forget about possible damage
to my liver. Will it make my skin
smoother?”
“Nurse, there’s a fly in
my IV!”
“In order to qualify for
medical benefits you have to
be 65, not feeling like 65!”
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ID-DEC-2011